Perception of Atrial Fibrillation Symptoms: Impact on Quality of life and Treatment in Older Adults

Abstract

Background:

In managing older adults with atrial fibrillation (AF), their symptomatology impacts their well-being and may inform treatment decision-making. We examined AF symptom perception, their impact on quality of life (QoL), and relation to treatment strategies in older adults with AF.

Methods:

Data was obtained from older adults with AF enrolled into a multicenter study conducted at clinic sites in Massachusetts and Georgia between 2016 and 2018. Participants were stratified into three age-groups: 65–74 (youngest-old), 75–84 (middle-old), and ≥85 (oldest). Perception of AF symptoms was assessed by participant self-report during their clinic visit and at study enrollment by the Atrial Fibrillation Effect on Quality-of-Life Questionnaire which assessed cardiac specific and non-specific, non-cardiac AF symptoms and their impact on QoL. Treatment strategies (rate or rhythm control) utilized were ascertained from electronic medical records.

Results:

Among the 1,184 participants (mean age 75 years, 48% women, 86% Non-Hispanic White), 51% were aged 65–74 years, 36% were 75–84 years, and 13% were ≥85 years. The most commonly reported AF symptoms were non-specific, non-cardiac symptoms (fatigue, dyspnea, lightheadedness) with similar prevalence and impact on QoL in all age-groups. Cardiac specific AF symptoms (palpitations, irregular heartbeat, pause in heart activity) were less prevalent, but most commonly reported by the youngest participants (65–74 years), who endorsed considerable impact of these symptoms on their QoL. Overall, those who reported experiencing any AF symptoms during their clinic visit were more likely to have received rhythm compared with rate control (OR: 1.56; 95% CI: 1.18–2.04) with similar findings for all age-groups except those aged ≥85 years.

Conclusions:

Our findings suggests a high prevalence of non-specific, non-cardiac symptoms among older adults with AF and that cardiac-specific AF symptoms may exert considerable impact on their QoL. The presence of any AF symptoms may drive more rhythm control in a majority of older adults.

Introduction

Atrial fibrillation (AF) is the most common heart rhythm disorder among older adults and is associated with an increased risk of cardiovascular related morbidity and mortality [1–4]. The incidence of AF increases with advancing age, affecting approximately 1 in 10 American adults aged 65 years and older [5]. Although many patients with AF are minimally symptomatic, the onset of distressing cardiac or non-specific, non-cardiac symptoms such as palpitations, shortness of breath, and extreme fatigue, could predispose to impairment in patient’s quality of life (QoL), influence treatment decisions, and their healthcare utilization [6].

Assessing the perception of AF symptoms can be challenging since there can be a high degree of variability in the clinical manifestations of AF, not only between individuals but also within an individual over time [7]. The complexity of AF symptomatology is even more evident among older adults, since they often have a high burden of comorbid conditions and concomitant symptoms (e.g., shortness of breath from pulmonary disease or heart failure) that may overlap with their AF symptoms [8,9]. Prior studies have shown that in older adults with less severe AF symptoms, rate control is commonly prescribed, whereas rhythm control is typically considered the initial treatment approach in younger, more highly symptomatic patients with AF [10]. Current management approaches of AF are based on an individualized prognosis of risk versus benefit as well as patient preferences with shared decision making [11,12].

To the best of our knowledge, no recent studies have evaluated whether AF symptoms differ among older patients in different age strata, and how differences in the perception of various symptoms may relate to AF treatment approaches and important patient-centered outcomes including QoL.

Using data from the multi-center Systematic Assessment of Geriatric Elements in AF (SAGE-AF) study [13,14], we examined differences in AF symptom perception among the youngest-old (65–74 years), middle-old (75–84 years) and the oldest (≥85 years) patients, and the association between AF symptomatology, QoL, and treatment strategies (rate versus rhythm control).

Methods

Study Population

Data used in the present study were obtained from the SAGE-AF investigation, which has been previously described in detail [13,14]. In brief, study participants were recruited from four study sites in Central MA, including the University of Massachusetts Memorial Health internal medicine, cardiology, and electrophysiology practices, and Heart Rhythm Associates. There was one study site in Eastern MA, namely the cardiology clinic at Boston University Medical Center. In addition, participants were recruited from two study sites in Central Georgia, including the Family Health Center (general/family medicine practice) and Georgia Arrhythmia Consultants (electrophysiology practice). Between 2016 and 2018, eligible and consenting participants 65 years and older with a CHA2DS2-VASC risk score >=2 were recruited if they had a diagnosis of AF as detected by a Holter monitor, electrocardiography tracings, or based on documentation in any medical record. Ineligible participants were those unable to provide signed informed consent, non-English speaking, scheduled for an invasive procedure with high risk for uncontrolled bleeding, pregnant, incarcerated, unable to attend study follow-up visits, or if they had a documented absolute contraindication to using oral anticoagulants or a medical indication for oral anticoagulation aside from AF such as pulmonary embolism, deep venous thrombosis, or presence of a mechanical heart valve. A total of 6,507 patients were screened for eligibility at the study sites, and 1,244 eligible participants were enrolled in the study [13,14].

Trained research personnel abstracted relevant patient data from the electronic medical records (EMR) at participating study sites. In-person or telephone interviews were conducted with each participant at the time of enrollment and at scheduled follow-up visits. The Institutional Review Boards at the University of Massachusetts Medical School, Boston University, and Mercer University provided ethical approval for conducting this study. Each eligible participant provided written informed consent prior to formal study enrollment.

Baseline Participant Characteristics

Participant sociodemographic data including age and sex were obtained from the EMR. Age was categorized into three groups: 65–74 years (youngest-old), 75–84years (middle-old), and ≥85 years (oldest). Additional sociodemographic variables such as race/ethnicity, marital status, and highest level of education were derived from direct interviews with participants at the time of baseline study enrollment.

Detailed information on clinical characteristics was assessed from the EMR. Variables obtained included time since AF diagnosis, type of AF (paroxysmal, persistent, or permanent), baseline electrocardiogram tracing, and the presence of comorbidities (heart failure, hypertension, cardiomyopathy, myocardial infarction, angina, valvular heart disease, stroke, dyslipidemia, peripheral vascular disease, diabetes mellitus, chronic liver disease, cancer, renal disease, depression, anxiety, anemia, arthritis, and thyroid disease). Risk scores including the Charlson Comorbidity Index, CHA2DS2-VASc, and HASBLED scores were derived from the patient’s medical history [16,17]. Review of participant medications available in the EMR was conducted and polypharmacy (receipt of ≥5 medications) was identified [18].

Several psychosocial and geriatric elements were assessed from structured participant interviews. Symptoms of anxiety and depression were evaluated with the 7-item Generalized Anxiety Disorder Scale [19] and 9-item Patient Health Questionnaire [20] respectively. A validated single-item measure evaluated self-rated health status with responses on a 5-point Likert scale as either excellent, very good, good, fair, or poor [21]. The Cardiovascular Health Survey (CHS) frailty scale was utilized in assessing frailty [22]. Social support was assessed with the 5-item Medical Outcomes Social Support Survey Instrument [23]. The instrumental activities of daily living assessed basic communication skills, transportation, meal preparation, shopping, housework, and managing medications and personal finances [24]. Cognitive impairment was assessed using the 30-item Montreal Cognitive Assessment Battery (MoCA) [25,26]. Hearing and visual impairment and health behaviors including alcohol use and smoking history were self-reported by participants at study enrollment.

Assessment of AF symptoms and QoL

Participant’s experience of AF symptoms was assessed in two ways. First, trained study personnel reviewed all provider notes for documentation of participant self-report of experiencing any AF symptom during their clinic visit. Study staff were trained to code AF symptoms as either present or absent based on the provider’s documentation.

In addition, all participants were administered the Atrial Fibrillation Effect Quality-of-Life (AFEQT) Questionnaire at the time of study enrollment to assess their perception of AF-related symptoms and their impact on QoL [15]. The AFEQT questionnaire is a 20-item validated disease-specific measure that asks respondents to self-report the extent to which their experience of AF may have affected their QoL in the prior 4 weeks using seven response options on a Likert scale including: “Not at all bothered Or I did not have this symptom Or No difficulty at all”, “Hardly bothered or difficult”, “A little bothered or difficult”, “Moderately bothered or difficult”, “Quite a bit bothered or Difficult”, “Very bothered or A lot of difficulty”, and “Extremely bothered or difficult”. The AFEQT questionnaire includes three subscales, namely the “symptom”, “daily activities”, and “treatment concerns” subscales, respectively. We focused on the “symptom” and “daily activity” subscales which assessed participants’ experience of AF symptoms by asking the extent to which their symptoms may have been bothersome or difficult to cope with in the preceding 4 weeks. Symptoms including palpitations, pause in heart activity, and irregular heartbeat were classified as “cardiac-specific AF symptoms” whereas the “non-specific, non-cardiac AF symptoms” included fatigue, dyspnea, and lightheadedness/dizziness.

To examine the impact of each cardiac-specific and non-specific, non-cardiac AF symptom on participant’s QoL, we assessed the proportion of those who reported their symptom as being either hardly bothersome or difficult to cope with, little, moderately, quite a bit, and very or extremely bothersome or difficult to cope with in the preceding four weeks.

AF Treatment Strategies

During study enrollment, the modality of AF treatment for each participant was assessed from detailed review of the EMR and categorized as either rate or rhythm control. Study participants were classified as being on rate control if they were taking any prescribed rate control medication (beta-blockers, calcium channel blockers, or digoxin) whereas those on rhythm control were classified as such if they had undergone AF catheter ablation therapy, cardioversion, or were taking any prescribed anti-arrhythmic medications (amiodarone, dofetilide, dronedarone, flecainide, propafenone, or sotalol).

Statistical Analysis

In deriving the analytic sample (n=1,184) from the 1,244 recruited study participants, we excluded those with missing information from the AFEQT measure at baseline (n=60). Those excluded were more likely to be older (mean age: 78 years [SD=8.0] versus 75 years [SD=7.0]), cognitively impaired (57.6% versus 35.2%), and a higher proportion reported severe symptoms of depression (8.3% versus 2.5%) (p<0.05 for all comparisons).

Descriptive statistics were used to examine differences in participants’ characteristics according to the three age categories: 65–74 years (youngest-old), 75–84 years (middle-old), and ≥85 years (oldest). Continuous variables were summarized as means and standard deviations when normally distributed and as medians and interquartile ranges when skewed. Categorical variables were reported as proportions. The non-parametric Wilcoxon rank-sum test was used in comparing continuous variables across the three age strata. The Cochran–Armitage test for trend was used for between group comparisons of categorical variables.

We assessed the prevalence of participant self-report of any AF symptoms during their clinic visits overall and across the three age strata.

Using the AFEQT questionnaire, we examined the extent to which participant’s QoL was impacted by their perception of cardiac-specific and non-specific, non-cardiac AF symptoms and differences in the proportion of patients endorsing an impact on their QoL by each AF symptom studied across the age categories.

We conducted sensitivity analysis, using stratified analysis to examine the potential impact of permanent/persistent AF versus paroxysmal AF on symptom reporting.

With multivariable adjusted logistic regression modeling, we examined the association between the presence of any AF symptom reported by participants during their clinic visit and the receipt of rhythm versus rate control, overall and in age stratified analyses. For multivariable adjustment, our choice of potentially confounding variables such as sex, race, level of education, presence of one or more comorbidities (categorized as 1–4, 5–7, 8 or more; consisting of heart failure, hypertension, cardiomyopathy, myocardial infarction, angina, valvular heart disease, stroke, dyslipidemia, peripheral vascular disease, diabetes mellitus, chronic lung disease, cancer, renal disease, depression, anxiety, anemia, arthritis, and thyroid disease), frailty, cognitive impairment, and social support was based on clinical or statistical significance.

Results

Baseline study population characteristics

The mean age of study participants (n=1,184) was 75 years (SD=7.0); 51% (n=606) were aged 65–74 years [youngest-old], 36% (n=429) were aged 75–84 years [middle-old], and 13% (n=149) were aged ≥85 years [oldest]. Approximately one-half of the study participants were women and 86% were Non-Hispanic White. The highest prevalence of women was among the oldest study participants (Table 1).

Table 1.

Baseline sociodemographic, psychosocial, and clinical characteristics of participants

Characteristics	Youngest-Old (65–74 years) (n=606)	Middle-Old (75–84 years) (n=429)	Oldest ≥ 85 years (n=149)	P value for trend
Socio-demographic
Age (yrs, mean, (sd))	69.8 (2.9)	78.9 (2.8)	88.2 (2.9)	<0.001
Women (%)	44.6	49.4	59.7	<0.01
Married (%)	62.2	57.4	33.8	<0.001
Race/Ethnicity (%)
Non-Hispanic White	84.5	86.6	92.6	0.01
Non-White	15.5	13.4	7.4
Education (%)
≤ high school	31.8	43.8	40.0	<0.01
Some college	19.7	19.9	17.9
College graduate	48.5	36.4	42.1
Clinical
AF Type (%)
Paroxysmal	71.7	63.1	54.1	<0.001
Persistent	14.6	15.6	12.6
Permanent	13.7	21.3	33.3
AF Diagnosis (yrs, mean (sd))	5.1 (4.2)	5.6 (4.5)	6.0 (4.3)	0.03
Baseline heart rate (mean (sd))	71 (13.6)	72 (13.2)	72 (12.4)	0.38
Baseline Electrocardiogram (%)
Sinus Rhythm	43.3	34.1	23.0	<0.001
Atrial fibrillation	25.5	31.0	43.2
Paced/Atrial flutter/Others	31.2	34.9	33.8
Anticoagulation therapy (%)
DOAC	39.9	38.9	22.1	<0.001
Warfarin	42.8	49.2	67.1
None	17.3	11.9	10.7
AF Treatment (%)
Rhythm control	63.2	52.5	47.0	<0.001
Rate control	36.8	47.5	53.0
Prior ablation therapy (%)	35.1	27.7	21.5	<0.001
Medical History (%)
Hypertension	89.9	89.3	94.6	0.23
Dyslipidemia	79.9	81.3	81.2	0.82
Heart Failure	30.5	42.0	51.7	<0.001
Diabetes	35.3	27.3	26.2	0.01
Arthritis	45.9	52.0	64.4	<0.001
Anemia	28.6	33.1	34.9	0.06
Cancer	25.4	35.4	33.6	<0.01
Common prescribed medications (%)
ACE-inhibitors	33.4	34.8	34.3	25.5
Beta-blockers	80.5	77.8	81.6	88.4
Calcium channel blockers	30.8	32.3	29.6	28.2
Diuretics	51.6	46.4	55.9	61.1
Statins	68.4	68.2	68.8	67.1
Polypharmacy (≥5 medications) (%)	30.5	27.5	21.5	0.03
Risk Scores (Mean, SD))
Charlson Comorbidity Index	5.1 (2.3)	6.7 (2.4)	7.7 (2.7)	<0.001
CHA2DS2-VASc	3.7 (1.4)	5.1 (1.6)	5.3 (1.4)	<0.001
HASBLED	3.1 (1.1)	3.3 (1.1)	3.4 (1.0)	0.01
Psychosocial and Geriatric
Low social support (%)	27.1	26.6	20.1	0.15
Visual Impairment (%)	36.0	30.3	38.3	0.68
Hearing Impairment (%)	27.1	41.0	60.4	<0.001
Cognitive impairment (%)	25.4	41.6	57.0	<0.001
Frailty (%)
Not Frail	41.1	28.2	16.1	<0.001
Pre-Frail	48.0	55.9	67.1
Frail	10.9	15.9	16.8
Depressive Symptoms† (%)
None	71.0	73.9	67.8	0.99
Mild/Moderate	25.7	24.2	30.9
Moderately Severe/Severe	3.3	1.9	1.3
Anxiety Symptoms‡ (%)
None	74.9	78.3	79.9	0.13
Mild/Moderate	22.8	20.8	16.8
Severe	2.3	0.9	3.3
Self-Rated Health (%)
Fair/Poor	16.6	16.7	15.6	0.85
Good/Excellent	83.4	83.3	84.4
Independent functioning (Mean, SD)	6.8 (0.8)	6.7 (1.1)	6.3 (1.5)	<0.001
Health behaviors
Any Alcohol use (%)	56.8	52.1	55.2	0.35
Smoking status (%)
Never smoker	45.0	46.1	54.1	0.04
Former smoker	50.7	51.5	44.5
Current Smoker	4.3	2.4	1.4

Abbreviations: CHA2DS2-VASc: Stroke risk assessment (Congestive heart failure, Hypertension, Age ( ≥ 65 = 1 point, ≥ 75 = 2 points), Diabetes, and prior Stroke/TIA (2 points), Vascular disease (peripheral arterial disease, previous MI, aortic atheroma) and female gender); HASBLED: Determines 1 year risk of major bleeding (Hypertension, Abnormal renal and liver function, prior Stroke, prior Bleeding, Labile INR, Elderly, Drugs or alcohol that increase risk of bleeding); DOAC: Direct Oral Anticoagulant

^†PHQ-9 Patient Health Questionnaire 9 item score (5–9 mild; 10–14 moderate; 15–19 moderately severe; and ≥20 severe depression)

^‡GAD-7 General Anxiety Disorder 7 item score (5–9 mild; 10–14 moderate; ≥15 severe anxiety); Independent functioning assessed by Instrumental Activities of Daily Living (score ranging from 0–7)

The average time since the study participants had been diagnosed with AF was 5.4 years. Those in the oldest age group had the longest duration of AF. Participants in the youngest age category were more likely to have been diagnosed with paroxysmal AF and to be in sinus rhythm based on the review of their baseline electrocardiogram compared with those in the middle-old or oldest age groups (Table 1). Permanent AF was most common among the oldest participants, who were also more likely to be in AF on their baseline electrocardiogram. The youngest participants were most likely to be on rhythm control and to have undergone ablation therapy while rate control was most commonly utilized in the oldest age group. Overall, participants who underwent catheter ablation had the procedure done between May 2009 – July 2017. Overall, 85% of study participants were on anticoagulation, approximately one-third on Direct-Acting Oral Anti-Coagulants (DOACs) and 48% on Warfarin. The oldest participants were most likely to be managed on Warfarin (Table 1).

The burden of comorbidities, risk of thromboembolic phenomenon, and bleeding complications based on the Charlson Comorbidity Index, CHA2DS2VASC, and HAS-BLED risk scores respectively, were highest among the oldest persons. Frailty and cognitive impairment were most prevalent among the oldest individuals. (Table 1).

Perception of AF symptoms

Approximately one-third of participants reported experiencing any AF related symptoms during their clinic visit, with those aged 65–74 years being most likely to have reported the presence of any AF symptom. The majority (61%) of our cohort were asymptomatic, and the proportion who reported no symptoms was particularly high among oldest adults (79%).

Based on the AFEQT questionnaire, the most prevalent AF symptoms were non-specific, non-cardiac in nature including fatigue (61%), dyspnea (56%), and lightheadedness/dizziness (38%), with no significant difference in the prevalence of these symptoms according to age. The cardiac specific AF symptoms were less commonly experienced by participants and included palpitations (36%), irregular heartbeat (33%), and pause in heart activity (18%), all of which were most commonly reported by patients aged 65–74 years. Table 2 shows the proportion of participants who report experiencing cardiac-specific and non-specific, non-cardiac symptoms of AF across the age groups.

Table 2.

Perception of Cardiac and Non-Specific, Non-Cardiac Atrial Fibrillation Symptoms by Age

Symptom perception	Youngest-Old (65–74 years) (n=606)	Middle-Old (75–84 years) (n=429)	Oldest ≥ 85 years (n=149)	P-value for trend
AF symptoms in the preceding 4 weeks (%)	33.6	26.1	21.4	<.0.001
Palpitations (%)	41.8	30.5	28.2	<0.001
Irregular heartbeat (%)	38.8	28.7	21.5	<0.001
Pause in heart activity (%)	20.8	14.9	12.8	<0.01
Lightheadedness/Dizziness (%)	39.4	36.6	36.9	0.40
Dyspnea (%)	53.6	56.6	60.4	0.11
Fatigue (%)	58.8	62.5	63.1	0.20
% are reported as column percentages

Self-reported impact of AF symptoms on QoL

In terms of the impact of cardiac specific AF symptoms on QoL, among those who experienced palpitations (n=426), one-third reported little/moderate impact of palpitations on their QoL while 6% endorsed an extreme impact of palpitations on their QoL. Among the 390 participants who experienced an irregular heartbeat, 28% and 5% reported little/moderate and severe impact on their QoL, respectively. Among the 209 participants who perceived a pause in their heartbeat, 15% endorsed little/moderate, and only 2% reported an extreme impact on their QoL. Participants aged 65–74 years most commonly reported an extreme impact of each of the cardiac specific AF symptoms on their QoL as compared to the other two age groups (Figure 1).

Figure 1:

Participant Self-reported Impact of Atrial Fibrillation symptoms on Quality of Life by Age Groups

With regards to the non-specific, non-cardiac AF symptoms, among the 694 participants who reported being fatigued, up to one-half experienced little/moderate impact on their QoL, and one in ten reported an extreme impact on their QoL. Among the 658 patients who experienced symptoms of dyspnea, 44% reported little/moderate impact, and 12% reported very difficult or extreme impact of dyspnea on their QoL. In those who reported experiencing lightheadedness/dizziness (n=433), approximately one-third had little/moderate impact, and 6% reported an extreme effect on their QoL. No significant differences were observed in the impact of these non-specific, non-cardiac AF symptoms on QoL according to age. The self-reported impact of AF on QoL across age groups is shown in figure 1.

From our sensitivity analysis, overall, participants with paroxysmal AF compared to those with permanent/persistent AF were more likely to report experiencing symptoms during their clinic visit (32% vs 26%; p=0.04). However, no differences were observed across age-groups in symptom reporting by paroxysmal versus permanent/persistent AF. With regards to the impact of AF symptoms on QoL, participants with paroxysmal AF were more likely to report experiencing an extreme impact of palpitations on their QoL than those with permanent/persistent AF (8% vs 4%; p=0.02). Those with persistent/permanent AF were more likely to report a moderate impact of dyspnea on their QoL (53% vs 40%; p<0.001). No differences were observed in the terms of the impact of symptoms on QoL according to type of AF in the three older age groups examined.

Association between AF symptoms and Treatment Strategies

Overall, after controlling for a number of potentially confounding demographic and clinical factors, individuals who reported the presence of any AF symptom during their clinic visit were more likely to be on rhythm compared with rate control therapy (OR: 1.55; 95% CI: 1.18–2.04) with this association remaining statistically significant among the youngest-old (OR: 1.61; 95% CI: 1.10–2.35) and middle-old (OR: 1.62; 95% CI: 1.01–2.60) participants (Table 3).

Table 3.

Association between Symptomatic Atrial Fibrillation and Rhythm versus Rate Control: Overall and Stratified Analysis by Age

	Overall Unadjusted OR (95% CI) (n=1,147)	Overall Adjusted OR (95% CI) (n=1,116)	65–74 years Adjusted OR (95% CI) (n=579)	75–84 years Adjusted OR (95% CI) (n=396)	≥ 85 years Adjusted OR (95% CI) (n=141)
No AF symptom	Ref	Ref	Ref	Ref	Ref
AF symptom	1.56 (1.20–2.03)	1.55 (1.18–2.04)	1.61 (1.10–2.35)	1.62 (1.01–2.60)	1.07 (0.44–2.60)
Sex
Female	Ref	Ref	Ref	Ref	Ref
Male	1.10 (0.87–1.39)	1.12 (0.88–1.42)	1.25 (0.88–2.35)	1.32 (0.87–2.00)	0.35 (0.16–0.79)
Race
White	Ref	Ref	Ref	Ref	Ref
Non-White	0.78 (0.56–1.08)	0.81 (0.56–1.18)	0.79 (0.47–1.33)	0.56 (0.29–1.09)	0.74 (0.17–3.12)
Education
≤ High School	Ref	Ref	Ref	Ref	Ref
Some College	0.95 (0.68–1.31)	0.87 (0.62–1.23)	0.74 (0.44–1.24)	0.90 (0.52–1.58)	1.10 (0.39–3.07)
College grad	1.01 (0.78–1.31)	0.99 (0.74–1.32)	0.80 (0.52–1.24)	1.15 (0.70–1.88)	1.26 (0.55–2.88)
Comorbidities
1–4	Ref	Ref	Ref	Ref	Ref
5–7	0.98 (0.75–1.28)	1.07 (0.81–1.42)	1.11 (0.74–1.65)	1.17 (0.72–1.90)	1.12 (0.45–2.75)
8 or more	1.45 (1.07–1.95)	1.61 (1.17–2.22)	1.63 (1.00–2.65)	1.60 (0.91–2.80)	2.15 (0.79–5.86)
Frailty
Not frail	Ref	Ref	Ref	Ref	Ref
Pre-Frail	0.91 (0.70–1.17)	0.90 (0.69–1.19)	0.93 (0.64–1.37)	0.93 (0.58–1.50)	1.50 (0.51–4.43)
Frail	1.06 (0.73–1.54)	1.00 (0.64–1.54)	0.86 (0.46–1.63)	1.13 (0.55–2.33)	2.24 (0.53–9.51)
Cognition
Not impaired	Ref	Ref	Ref	Ref	Ref
Impaired	1.44 (1.13–1.83)	1.41 (1.07–1.86)	1.22 (0.77–1.92)	1.22 (0.77–1.92)	1.18 (0.55–2.53)
Social support
Adequate	Ref	Ref	Ref	Ref
Low	1.11 (0.85–1.44)	1.07 (0.81–1.41)	1.23 (0.82–1.83)	0.82 (0.51–1.31)	1.20 (0.48–2.98)

The Multivariable models overall and by age group, are adjusted for variables with clinical or statistical significance including sex, race, level of education, presence of one or more comorbidities, frailty, cognitive impairment, and social support.

Discussion

In this contemporary cohort of individuals 65 years and older with AF, the most commonly reported symptoms were non-specific, non-cardiac in nature with no significant differences in their prevalence or impact on QoL in the age groups studied. The cardiac specific AF symptoms were most commonly experienced by participants aged 65–74 years who also reported an extreme impact of these symptoms on their QoL. Overall, participants who reported the presence of any AF symptoms to their provider were more likely to be on rhythm versus rate control therapy, with a similar pattern of treatment observed in all but the oldest participants aged ≥85 years.

Our youngest study participants aged 65–74 years had the highest burden of cardiac specific AF symptoms with a considerable impact on their QoL compared with their older-aged counterparts. The higher prevalence of paroxysmal AF among our youngest study participants may have contributed to a greater likelihood of experiencing AF symptoms. Our results are consistent with findings from AF based population studies such as the ORBIT-AF registry of 9,542 American adults with incident and prevalent AF which showed that younger patients with a new AF diagnosis had lower QoL scores on the AFEQT [27]. A plausible explanation for this observation is that older individuals may have learned to live and cope with their symptoms and be less likely to report any burden or impact on their QoL compared with younger persons who may report higher burden of symptom severity due to the anxiety of living with their new diagnosis or perceiving their symptoms as being intrusive to performing their daily activities [28]. Healthcare providers should be aware of the varying impact of cardiac specific AF symptoms on patient’s QoL among those of different ages and promote individualized strategies in the delivery of patient-centered care and reduction of AF related morbidity.

While we observed a high prevalence of non-specific, non-cardiac symptoms in our study population, no particular age group was more likely to report experiencing these symptoms or impact on their QoL. In the Prevention of Thromboembolic Events–European Registry in Atrial Fibrillation with approximately 6,000 patients (mean age: 71 years), 65% reported experiencing fatigue at the time of study enrollment [29]; in the present study, 61% of participants reported that they experienced symptoms of fatigue in the preceding four weeks. These findings buttress the need for a holistic approach in the management patient’s symptoms of AF, as older adults are more likely to have several coexisting comorbidities and present with non-specific, non-cardiac symptoms. Inasmuch, patients should be duly advised to avoid delays in seeking treatment or attributing their symptoms to the normal aging process or other non-cardiac related causes. Of concern are reports from qualitative research that suggest that healthcare providers may dismiss non-cardiac specific symptoms as not warranting further cardiac work-up or inaccurately attribute patient symptomatology to other pathologic processes such as anxiety, with consequent delay in management [30]. It is worthwhile to note that since the presence, type, or severity of AF symptoms may not necessarily align with the potential risk or complications of AF [31], healthcare providers should have a high degree of suspicion of AF among older adults and conduct appropriate assessments to ensure prompt diagnosis and treatment.

In the present study, although the oldest group of participants had the highest proportion of women, burden of comorbid heart failure, and permanent AF, we observed that they were less likely to report experiencing more symptoms or worse AF related QoL. This finding is in contrast to our prior investigation using the SAGE-AF data [13], where our findings suggested that among all study participants irrespective of age, women, and those with heart failure tended to have lower AF related QoL at study baseline and over one year of follow up.

Study participants who reported experiencing any symptom associated with AF during their clinic visit were more likely to be on rhythm compared with rate control therapy, and this association persisted among all except the oldest participants. Our findings are consistent with previous studies that have shown that rhythm control is more commonly implemented in younger or highly symptomatic patients [10]. Rate control strategies are instituted to control the ventricular heart rate while the objective of rhythm control therapy is to ensure that AF converts to normal sinus rhythm, which is maintained over time [32]. Despite these different treatment approaches, both rate and rhythm control strategies have been shown to lead to similar patient related outcomes [33,34]. In the current paradigm of AF management, the presence of symptoms is an important consideration for selecting rhythm control strategy [35]. In managing patients with concomitant persistent AF and heart failure, rhythm control strategies including catheter ablation therapy, were shown to be effective in restoring sinus rhythm leading to improved functional capacity and alleviation of heart failure symptoms in the CAMTAF and CAMERA-MRI trials; however, these trials were conducted in younger aged individuals <65 years [36,37]. In much older persons with coexisting AF and heart failure, patients who were treated with a rhythm control strategy were more likely to experience worse clinical outcomes after age 75 in the CABANA trial [38]; or higher all-cause mortality in those aged 65 years and older in the AFFIRM trial [35]. These findings emphasize the need for shared decision making between patients and clinicians regarding the benefits and risks of rhythm control strategies, especially in much older patients with comorbid heart failure, who may be at risk of worse clinical outcomes and decreased survival.

The lack of an acceptable or standardized clinical approach for assessing AF symptomatology poses a significant challenge in AF management and the complex clinical decision-making process [7]. Therefore, healthcare providers should pay close attention to patients self-reported symptoms of AF as well as their overall functional status before proceeding with treatment options, due to the underlying cost implications and potential complications attributable to both pharmacologic and non-pharmacologic strategies in AF management.

Study strengths and limitations

There are several strengths of the present study. First, to the best of our knowledge, this is the first contemporary inquiry into patient’s perception of cardiac and non-cardiac specific AF symptoms and their impact on QoL and treatment strategies in older men and women of different ages using a well characterized multi-center cohort of patients with a clinical diagnosis of AF. Second, the AFEQT questionnaire utilized in assessing the impact of AF symptoms on QoL is a validated and widely accepted measure, enhancing the validity and reproducibility of our results. Information about the specific treatment strategies patients received was obtained from the review of patient’s EMR by trained research personnel which reduced the likelihood of misclassification of treatment approaches from patient self-reports. Despite these strengths, our results should be interpreted taking into consideration some limitations. A limitation of our study findings is the absence of a control group of older adults without AF. This would have provided an opportunity to fully elucidate the proportion of symptoms attributable to AF, since symptoms such as palpitations and dizziness could occur commonly in older adults and are not specific to AF. Also, participants may have been misclassified into the rate control group due to missing records on ablation therapy for older participants. Furthermore, study participants were recruited from clinic sites located only in the Northeastern and Southeastern regions of the US, which raises concern for potential selection bias and limited generalizability of our findings to more ethnically diverse groups. Since AF symptoms and QoL were simultaneously measured with the AFEQT questionnaire, we could not further assess for temporality or causality. Future longitudinal studies should be designed that separately assess AF symptomatology and patient’s functional status with multiple assessments over long follow-up periods to identify high-risk periods where early interventions may be most beneficial for different age groups of patients with AF.

Conclusions

Healthcare providers, patients, and their caregivers should be increasingly aware of the common occurrence of non-specific, non-cardiac symptoms in older patients with AF, irrespective of their age. Patients aged 65–74 years, were most likely to have been diagnosed with paroxysmal AF and to report a high symptom burden from cardiac specific AF symptoms. A majority of participants aged 85 years and older were asymptomatic. The presence of symptoms was associated with being on rhythm versus rate control for all participants except those 85 years and older. Our findings have important implications in the present era where the goals of therapy are both patient-centered and clinically driven with shared decision making to reduce the associated symptom burden, improve overall patient well-being, and ultimately decrease AF related morbidity and mortality.

Key Points.

• Older adults with atrial fibrillation commonly report non-specific, non-cardiac symptoms.

• Persons aged 65–74 years had a greater burden of AF specific cardiac symptoms than older individuals.

• Older adults who self-reported AF symptoms were more likely to be on rhythm control except those ≥85 years.

Why does this paper matter?

Healthcare providers and caregivers should be aware of the high prevalence of non-specific, non-cardiac symptoms of atrial fibrillation among older adults, and that the presence of more cardiac-specific symptoms may exert considerable impact on an individual’s quality of life. Patient symptomatology is associated with a higher likelihood of being on rhythm control therapy except in those aged 85 years and older.

Abbreviations

AF

Atrial fibrillation

AFEQT

Atrial Fibrillation Effect Quality-of-Life Questionnaire

CHA2DS2-VASc

Congestive heart failure, Hypertension, Age, Diabetes, Prior Stroke/TIA, Vascular disease, Sex Category

CHS

Cardiovascular Health Study

DOAC

Direct Oral Anticoagulants

HASBLED

Hypertension, Abnormal renal and liver function, prior Stroke, prior Bleeding, Labile INR, Elderly, Drugs or alcohol that increase risk of bleeding

IADLs

Instrumental Activities of Daily Living

MOCA

Montreal Cognitive Assessment Battery

QoL

Quality of Life

SAGE-AF

Systematic Assessment of Geriatric Elements in AF