The American Journal of Medicine
Volume 119, Issue 5 , Pages 448.e1-448.e19, May 2006

Quality of Life in Patients with Atrial Fibrillation: A Systematic Review

Cardiovascular Psychophysiology Unit, University Department of Medicine, City Hospital, Birmingham, United Kingdom

Received 9 July 2005; accepted 31 October 2005.

Article Outline

Abstract 

The impact of atrial fibrillation (AF) on patients’ quality of life (QoL) has yet to be fully elucidated in a systematic manner. This article examines QoL in “general” patients with AF as well as the effects that rate and/or rhythm-control interventions have on QoL. Patients with AF have significantly poorer QoL compared with healthy controls, the general population, and other patients with coronary heart disease. Studies examining rate or rhythm-control strategies alone demonstrate improved QoL after intervention. Three of the four large randomized control trials (STAF, PIAF, RACE) comparing rate versus rhythm control demonstrated a greater improvement in QoL in patients receiving rate control. However, the AFFIRM trial revealed a similar improvement in QoL for both rate and rhythm-control groups. The data, although frequently compromised by various methodologic weaknesses, suggest that patients with AF have impaired QoL, and that QoL can be significantly improved through rate or rhythm-control strategies.

Keywords:  Atrial fibrillation , Rate and rhythm-control interventions , Quality of life

 

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disorder and is associated with substantial morbidity and mortality from heart failure, stroke, and other thromboembolic complications.1 AF also results in frequent hospital visits and readmissions, with recent estimates suggesting that the direct cost of AF to the United Kingdom National Health Service in 2000 was £459 million, accounting for 2.4% of National Health Service expenditure.2 Analogous figures are not available for the United States; however, a recent editorial3 states that similar economic costs are probably because the cost of acute hospital admissions and total Medicare payments were significantly higher in patients with AF.4 The high costs associated with AF are primarily related to the complexity of its management, which typically relies on rate and/or rhythm control of ventricular rate.5

Although the epidemiology, clinical consequences, and costs of AF have been subject to considerable study, less attention has been paid to patient-related issues, such as quality of life (QoL). The concept of QoL emerged in the late 1940s, when the World Health Organization extended the definition of health to encompass the presence of physical, mental, and social well-being.6 Since the 1980s, QoL issues have become more important in health care practice and clinical research, with a search of the Cochrane Controlled Trials Register demonstrating an increase from 0.34% in 1980 to 3.6% in 1997 in the number of cardiovascular trials reporting QoL as an end point.7

Assessment of QoL has been used for a variety of purposes in a health care setting: to screen for psychologic morbidity; to prioritize patients for various treatment regimens; to determine the choice of treatment; to monitor patients’ progress; and as an outcome measure in research studies and clinical trials.7, 8, 9 QoL is particularly relevant to the treatment of chronic conditions such as AF, a condition that is not immediately life-threatening but is likely to cause a substantial impairment in QoL.10 A previous review of QoL studies in patients with AF revealed various methodologic weaknesses including small sample sizes, nonvalidated questionnaires, and highly selective patient populations. However since this review was undertaken, a number of new interventions, including pulmonary vein (PV) isolation, implantable defibrillators, and the Maze operation, have become more common procedures for symptomatic patients with AF. The impact of such interventions on QoL has not been reviewed. In addition, a number of recent randomized controlled trials have examined the impact of rate versus rhythm-control strategies on QoL.11, 12, 13, 14 With rapid medical advances and subsequent reductions in mortality, variations in QoL may be the only reliable way of differentiating between treatment options, particularly in terms of patient preferences for various treatments.

Clinical significance

 

•Whereas the epidemiology, clinical consequences, and costs of AF have been subject to considerable study, less attention has been paid to patient-related issues, such as quality of life (QoL).

•Patients with AF have significantly poorer QoL compared to healthy controls, the general population, and other CHD patients.

•QoL can be significantly improved through appropriate use of rate or rhythm control strategies in AF patients.

The aim of this review is to evaluate systematically the QoL in patients with AF and the effects of rate and rhythm-control strategies on their QoL. In addition, major methodologic weaknesses will be highlighted and recommendations regarding the design of future studies will be made.

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Methods 

Search Strategy 

The electronic databases MEDLINE (1966 to January 31, 2005), EMBASE (1980 to January 31, 2005), PSYCHINFO (1887 to January 31, 2005), and CINAHL (1980 to January 31, 2005) were searched to identify potential articles. The following search terms were entered as Medical Subject Heading (MeSH) terms and textwords, or their equivalent, in the various databases: “Atrial Fibrillation,” “Atrial Flutter,” “Arrhythmia,” “Paroxysmal Atrial Fibrillation,” “Persistent Atrial Fibrillation,” “Permanent Atrial Fibrillation,” “Chronic Atrial Fibrillation,” “Lone Atrial Fibrillation,” “Silent Atrial Fibrillation,” “Quality of Life,” “Well-Being,” “Patients Perception,” “Catheter Ablation,” “Maze Surgery,” “Pacemaker,” “Cardioversion,” “Rate Control,” “Rhythm Control,” “Ventricular Function,” “Intervention,” “Pharmacological Intervention,” “Non-pharmacological Intervention,” and “Non-interventional.”

To identify any unpublished studies, abstracts from national (British Cardiac Society, Medical Research Society, Health Psychology) and international (American College of Cardiology, European Society of Cardiology, Society of Behavioural Medicine) cardiology and psychology conferences in 2003 and 2004 were inspected. Further, dissertation abstracts from UMI Proquest Digital Dissertations (1861 to January 31, 2005) were also searched to identify possible studies. The reference lists of all articles yielded by the electronic database search were scrutinized to identify any other potentially relevant articles.

Inclusion and Exclusion Criteria 

Studies with any duration of follow-up and in any language were eligible for inclusion. Studies were excluded if they did not assess QoL; included patients with other types of arrhythmia or other cardiac disease (eg, coronary artery bypass graft surgery, postmyocardial infarction, and heart failure), unless the data were reported separately for the patients with AF; included patients with AF as a subset in subsequent reports; or presented data only in abstract form. To be comprehensive and demonstrate the range of assessments of QoL in this patient group, all studies assessing QoL by interview, validated questionnaire, with a single question, or QoL diary were eligible for inclusion in this review. This latter criterion was adopted to properly reflect the variety of QoL measures used.

Data Extraction 

From the list of studies generated by the various search techniques, 2 of the authors (G.T., D.L.) independently selected suitable studies according to Cochrane Review criteria.15 If the title and abstract contained sufficient information to determine that the article did not meet the inclusion criteria, it was rejected. The full articles of all remaining titles and other potentially relevant articles identified by other search strategies (reference checking and personal communications) were then retrieved and independently reviewed (G.T., D.L.).

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Results 

The searches resulted in 593 citations, of which 49 studies11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60 published between 1988 and 2005 met the inclusion criteria (Figure 1). All included studies were written in English with the exception of one, which was translated from German. The majority (89.8%) of studies assessed QoL in patients with AF after intervention,11, 12, 13, 14, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60 with only 5 studies16, 17, 18, 19, 20 examining QoL in a “general” population with AF. In addition, the majority of studies did not randomize patients to the interventions,29, 30, 43, 55, 60 and most failed to use a control group.20, 21, 22, 23, 24, 37, 38, 39, 40, 41, 42, 43, 44, 46, 47, 48, 49, 50, 51, 52 The details of the included studies are summarized separately into noninterventional observational studies (Table 1), interventional studies examining the effect of rate control (Table 2) and rhythm control (Table 3), and studies comparing the effect of rate versus rhythm-control strategies (Table 4) on QoL in patients with AF.

Table 1. Summary of Noninterventional Studies Examining Quality of Life in Patients with Atrial Fibrillation
Author, Year, PlaceStudy Design (follow-up period)Participants (mean ± SD age, y)Measure of Quality of LifeResultsStudy Limitations
Dorian et al (2000)16 CanadaCross-sectional152 PAF pts. (52±12) vs 47 healthy controls (54±14) vs 69 PTCA pts. (62±9)
➢SF-36
➢Pts. with AF reported a significant ↓ QoL compared with healthy controls (P<.001) and pts. who underwent PTCA†
➢Fewer healthy controls than pts.

Paquette et al (2000)17 USAProspective (12 mo)170 pts. with AF 62 women (68±9) vs 108 men (62±11)
➢SF-36
➢Men and women demonstrated similar MCS at baseline (48.0±10.0 vs 47.6±10.8); P>.05)

➢Women had significantly ↓ PCS at baseline compared with men (36.1±8.8 vs 45.2±7.8; P<.01)

➢Women demonstrated a significant ↑in PCS only over 12-mo follow-up (36.1±8.8 to 38.5±9.5; P<.05)

➢Men demonstrated a significant ↑in MCS only over 12-mo follow-up (47.6±10.6 to 50.4±10.9; P<.05)
➢Males and females not age-matched

➢No appropriate control group

Howes et al (2001)18 USAProspective52 male pts. with chronic AF (77±7.2) vs 48 males in SR (76±6.4)
➢SF-36
➢Pts. and controls had similar PCS (43.0±11.0 vs 45.9±10.4; P = .24) and MCS (52.5±9.6 vs 55.3±8.4; P = .07)
➢Small sample size

van den Berg et al (2001)19 The NetherlandsCross-sectional73 pts. with PAF (54.1±13.4) vs age- and sex-matched healthy controls (45-55)
➢SF-36
➢Pts. with AF had a significant ↓ QoL (P<.05), except on pain subscale, compared with healthy controls (P = .73)
➢Small sample size

Kang et al (2004)20 USAProspective81 pts. with newly diagnosed AF (<3 mo) (67.3)
➢SF-36
➢PCS and MCS were significantly ↓ in pts. with AF than US general population (38.5±11.5 vs 50.0 and 48.7±11.5 vs 50.0; P<.05), respectively
➢Small sample size

➢No control group

➢Reported only mental and physical health summary scores

AF = atrial fibrillation; MI = myocardial infarction; MCS = Mental Component Summary score on the SF-36; PAF = paroxysmal atrial fibrillation; PCS = Physical Component Summary score on the SF-36; PTCA = percutaneous transluminal coronary angioplasty; pts. = patients; QoL = quality of life; SD = standard deviation; SF-36 = Medical Outcome Survey Short Form-36; SR = sinus rhythm; ↑ = increased; ↓ = decreased; < =less than; > = greater than;

† P value not reported.

Table 2. Summary of Studies Examining the Effect of Rate Control on Quality of Life in Patients with Atrial Fibrillation
Author, Year, PlaceStudy Design (follow-up period)Participants (mean ± SD age, y)InterventionMeasure of Quality of LifeResultsStudy Limitations
Studies examining rate-control strategies alone
AV node/ junction and bundle of HIS ablation ± pacing
Kay et al (1988)21 USAProspective (6 wk)12 pts with PAF (67)Radiofrequency catheter ablation of AV junction and pacing
➢McMaster Health Index

➢PGWB questionnaire
➢Significant ↑ in QoL (P = .002) and well-being (P = .001) after intervention
➢Small sample size

➢No control group

➢Short follow-up period

Natale et al (1996)22 USAProspective (12 mo)12 pts. with chronic AF (69±9)Radiofrequency catheter ablation of AV junction and pacing
➢Customized questionnaire to assess physical functional capacity and well-being
➢Significant ↑ in well-being (P<.001) postintervention
➢Small sample size

➢No control group

➢Nonvalidated QoL instrument

Kay et al (1998)23 USA

ABLATE AND PACE TRIAL

Prospective (12 mo)156 pts. with chronic symptomatic AF (61.1±11.5)Radiofrequency catheter ablation of bundle of HIS and permanent pacemaker implantation
➢Health status questionnaire

➢QoL index: cardiac version III
➢Significant ↑ in QoL (P<.001) on all 8 health status subscales postintervention

➢Significant ↑ in QoL from baseline to 3 mo (P<.05), with no further improvement at 12 mo (P>.05)

➢Significant ↑in QoL index over time (20.4 ± 4.7 to 23.0 ± 5.2; P = .0001)
➢Highly symptomatic pts.

➢No control group

Marshall et al (1998)24 UKProspective (6 wk)18 pts. with PAF (63)Radiofrequency catheter ablation of AV node and pacemaker implantation
➢PGWB questionnaire

➢McMaster Health Index
➢Significant ↑ in QoL assessed by PGWB after intervention (59.4 to 77.2; P<.01)
➢Small sample size

➢Highly symptomatic pts.

➢No control group

Levy et al (2000)25 UKProspective (1 mo)15 pts. with PAF (62±9)Radiofrequency catheter ablation of AV node and pacemaker implantation
➢Modified Karolinska questionnaire
➢Significant ↑ in QoL after 1 mo of pacing (59.0 ± 24.0 to 36.0 ± 24.0; P = .001)
➢Small sample size

➢Highly symptomatic pts.

➢Short follow-up period No control group

Takahashi et al (2003)26 JapanProspective (6 mo)38 pts. with symptomatic PAF and persistent AF (69±12)Radiofrequency catheter ablation of AV node and pacing
➢WHO-26
➢Significant ↑ QoL and general health (2.4 ± 0.5 to 3.1 ± 0.8; P<.01) and physical health (2.8 ± 0.8 to 3.5 ± 0.8; P<.01) post-ablation therapy
➢Small sample size

➢No control group

Studies comparing different rate-control strategies
(a) AV node/junction ablation/modification ± pacing and/or pharmacologic rate control
Fitzpatrick et al (1996)27 USARetrospective (2.3 ± 1.2 y)90 pts. with AF:36 pts. with PAF (59±12) and 54 pts. with chronic AF (61±16)Radiofrequency catheter ablation of AV junction with single pacing in pts. with chronic AF vs radiofrequency catheter ablation of AV junction with dual chamber pacing in PAF pts
➢Customized QoL questionnaire
➢Significant ↑ in QoL and ease of daily living postintervention (1.9 ± 1.2 to 3.6 ± 1.1; P<.001)
➢No control group

➢Nonvalidated QoL instrument

Lee et al (1998)28 TaiwanProspective, randomized (6 mo)60 pts. with PAF/permanent AF (AV ablation group: 69±9, AV junction modification group: 66±10)30 pts. to AV junction ablation with permanent pacing vs 30 pts. to AV junction modification
➢QoL diaries
➢Significant ↑ QoL in both the ablation (3.2 ± 1.2 to 1.0 ± 0.8; P<.05) and modification groups (3.1 ± 1.1 to 1.7 ± 0.7; P<.05) postintervention

➢Greatest ↑ in Qol in AV junction ablation and pacing group (P<.05)
➢Nonvalidated QoL instruments

Twidale et al (1998)29 USAProspective (4 wk)44 pts. with chronic AF with congestive heart failure (69.7±10.2)22 pts. to radiofrequency catheter ablation of AV node and pacemaker implantation vs 22 pts. radiofrequency catheter AV node modification
➢Minnesota LHFQ
➢Significant ↑ in QoL in AV node ablation and pacing group postintervention (66.1 ± 22.6 to 36.9 ± 17.1; P<.01)

➢No change in QoL for pts. who had successful AV node modification (P>.05)
➢Highly symptomatic pts.

➢Nonrandomized

➢Groups not age-matched

Natale et al (1999)30 USAProspective (6 mo)
➢75 pts. with chronic AF

➢(Group 1: 68.4±7

➢Group 2: 69.2±10.1

➢Group 3: 69.8±11.3)
Group 1: AV node ablation, pacemaker implantation plus drug therapy

Group 2: AV node ablation, pacemaker implantation without drug therapy

Group 3: Pacemaker implantation and drug therapy
➢QoL enjoyment and satisfaction questionnaire Perception of well-being
➢Significant ↑ in QoL from baseline to 6 mo for groups 1 (24 ± 2.1 to 55 ± 3.0; P<.001) and 2 (22 ± 2.0 to 30 ± 4.6; P<.001)

➢Significant ↑in well-being from baseline to 6 mo for groups 1 (1.2 ± 0.3 to 31.1 ± 0.4; P<.001) and 2 (1.3 ± 0.4 to 2.0 ± 0.4; P<.05)

➢No change in QoL for group 3 (P>.05)
➢Not randomized to treatment arms

➢No placebo medication for pts. in Group 2

Levy et al (2001)31 UKProspective, randomized (12 mo)36 pts. with permanent AF (69±7)18 pts. to bundle of HIS ablation and permanent pacing vs 18 pts. to permanent pacing and AV-modifying drugs
➢Karolinska questionnaire

➢Nottingham Health Profile
➢Baseline QoL similar in both groups (P>.05)

➢Significant ↑ in QoL in both groups postintervention (P<.05)
➢Small sample size

Brignole et al (2002)32 ItalyProspective, randomized, longitudinal (12 mo)141 pts. with PAF (antiarrhythmics group: 67±8; no drug therapy group: 69±8)AV junction ablation and pacing ± antiarrhythmic drugs postintervention
➢Minnesota LHFQ
➢Significant ↑ in QoL in both groups over time after intervention (P<.05)

➢No differences in improvements in QoL after intervention (P = .54)
➢Heart failure-specific QoL instrument (although 27 pts. also had heart failure)

PAF-2 trial
Duff et al (2003)33 CanadaProspective (6 mo)28 pts. with drug-refractory AFAV junction ablation and pacing with rate responsive mode on (n = 14) or off (n = 14)
➢SF-6

➢Arrhythmia Syndrome Scale

➢Ladder of Life
➢↑ QoL for both groups in 10/12 QoL questions (P<.001)

➢No significant differences in QoL between groups (P>.05)
➢Small sample size

➢Highly symptomatic pts.

Weerasooriya et al (2003)34 AustraliaProspective (12 mo)99 pts. with permanent AF (68±8.6)49 pts. to AV junction ablation and pacing vs 50 pts. to pharmacologic ventricular rate control
➢AQoL

➢CAST QoL Questionnaire
➢Significant ↑ in QoL on AQoL for both groups (P<.05)

➢Significant ↑ in QoL on CAST QoL questionnaire in AV junction ablation group (P<.05)
AIRCRAFT
(b) Pharmacologic rate control vs pharmacologic rate control
Tse et al (2001)35 Hong KongProspective, randomized (6 mo)16 patients with chronic AF (63±9)7 pts. to digoxin vs 9 pts. to amiodarone
➢SF-36
➢No significant effect on QoL at follow-up for either groups (P>.05)
➢Small sample size

(c) Pacing alone
Tse et al (2004)36 Hong KongProspective, randomized (6 wk)38 PAF (74±9) and 39 persistent AF pts (70±11)VVIR or DDDR pacemaker implantation with VRP on or off
➢SF-36
➢No significant differences on any of the SF-36 subscales between VRP on or off groups†
➢Short-term follow-up period

AF = atrial fibrillation; AIRCRAFT = Australian Intervention Randomized Control of Rate in Atrial Fibrillation Trial; AQoL = Assessment of Quality of Life; AV = atrioventricular; CAST = Cardiac Arrhythmia Suppression Trial; CTAF = Canadian Trial of Atrial Fibrillation; DC = direct current; LHFQ = Living with Heart Failure Questionnaire; PAF = paroxysmal atrial fibrillation; PAF-2 = Paroxysmal Atrial Fibrillation-2 trial; PGWB = Psychological General Well-Being; pts. = patients; QoL = quality of life; SD = standard deviation; SF-6 = Medical Outcome Survey Form-6, SF-36 = Medical Outcome Survey Short Form-36; SR = sinus rhythm; VRP = ventricular response pacing; WHO-26 = World Health Organization 26-item Questionnaire, ↑ = increased; ↓ = decreased; < =less than; > = greater than;

† P value not reported.

Table 3. Summary of Studies Examining the Effect of Rhythm Control on Quality of Life in Patients with Atrial Fibrillation
Author, Year, PlaceStudy Design (follow-up period)Participants (mean ± SD age, y)InterventionMeasure of Quality of LifeResultsStudy Limitations
Studies examining rhythm-control strategies alone
(a) Percutaneous interventional studies
Dierkes et al (2003)37 GermanyProspective (2.1 y)33 patients with drug-refractory PAF (56.1 ± 9.9)Radiofrequency catheter ablation of right atrial isthmus region
➢SF-36
➢Significant ↑ QoL postablation (P<.05)
➢No control group

Erdogan et al. (2003)38 GermanyProspective (33.9 ± 11 mo)33 pts. with PAF (54.1±9.5)Radiofrequency catheter ablation of atrial foci
➢SF-36
➢Baseline QoL scores ↓ than age-matched general German population

➢Successful ablation significantly ↑ QoL scores on 7/8 subscales (P<.05)

➢Nonsuccessful ablation significantly ↑ QoL in only 2/8 subscales (P<.05)
➢No control group

Goldberg et al (2003)39 USAProspective (36 mo)33 pts. with PAF(51±18)Radiofrequency catheter ablation of right atrial foci and PV
➢SF-36
➢Significant ↑ in QoL on 7/8 subscales 12 mo postablation (P<.05), except bodily pain (P>.05)
➢No control group

Nilsson et al (2003)40 DenmarkRetrospective (6 mo)30 pts. with PAF (51±9)PV isolation
➢SF-36
➢Significant ↓ in QoL scores in 5/8 subscales before PV isolation compared with healthy population (P<.05) and ↓ in 6/8 subscales compared with hypertensive pts. (P<.05)

➢Significant ↑ in QoL scores in 7/8 subscales after PV isolation (P<.05), except bodily pain (P>.05)
➢Highly symptomatic pts.

➢Retrospective study

➢No control group

Tada et al (2003)41 JapanProspective (6 ± 3 mo)50 pts. with PAF (58±7)Segmental PV isolation ± antiarrhythmic drug therapy postintervention
➢SF-36
➢Significant ↑in PCS and MCS postablation therapy regardless of drug therapy (P<.001)
➢No control group

Calo et al (2004)42 ItalyProspective (3 mo and every 3 mo thereafter)74 pts. with PAF/permanent AF (57±7)Radiofrequency catheter ablation of multiple regions around the right atrium
➢SF-36
➢QoL scores before ablation significantly ↓ than general population (P<.05)

➢Significant ↑ on all subscales of SF-36 postablation (P<.001)
➢Highly symptomatic pts.

➢No control group

Chen et al (2004)43 USAProspective (6 mo)193 pts. with AF with (55±11) or without (57±8) impaired systolic functionPV isolation
➢SF-36
➢Significant ↑ QoL post-PV isolation in all QoL domains for those without impaired systolic dysfunction (P<.05)
➢Pts. not randomized

➢No control group

Purerfellner et al (2004)44 The NetherlandsProspective (6 mo)75 pts. with AF (53±11)PV isolation
➢SF-36
➢Baseline QoL scores significantly ↓ than healthy controls and AF controls (previously published data) (P<.001) except for physical functioning (P = .13) and bodily pain (P = .39)

➢Significant ↑ in PCS (45.4 ± 9.7 to 51.7±6.5; P<.0001) and MCS (44.5±11.3 to 51.7±8.7; P<.0001)
➢No control group

➢Highly symptomatic pts.

Gerstenfeld et al (2001)45 USAProspective (6 mo)30 pts. with PAF/persistent AF (SR group: 52±10; AF recurrence group: 48±14)Radiofrequency catheter ablation of atrial foci vs electrophysiologic mapping without ablation
➢Modified SF-36
➢Significant ↑ in all QoL subscales in pts. who underwent mapping with ablation (P<.05)

➢Significant ↑ in health distress only in pts. who underwent mapping without ablation (P<.05)

➢Similar ↑ in QoL regardless of whether the procedure was a success or not (P<.05)
➢Highly symptomatic pts.

(b) Surgical interventional studies
Jessurun et al (2000)46 The NetherlandsProspective (12 mo)41 pts. with PAF (49±8)Maze operation
➢SF-36
➢Significant impairment in QoL presurgery (P<.05) in 6/8 subscale

➢Significant ↑ QoL at 3 mo after successful operation, except bodily pain (P = .85) and role limitation because of emotions (P =.09)

➢No significant ↑QoL from 3 to 12 mo (P>.05)
➢Small sample size (QoL only assessed in 18 pts.)

➢No control group

Lonnerholm et al (2000)47 SwedenProspective (12 mo)30 pts. with PAF/persistent AF and 18 pts. with permanent AFMaze operation
➢SF-36
➢Presurgery QoL significantly ↓ than general Swedish population†

➢Significant ↑ in QoL at 6 and 12 mo on all scales (P<.001) except for bodily pain (P =.09)
➢No control group

Jessurun et al (2003)48 The NetherlandsProspective, randomized (12 mo)35 pts. with AF (64)Randomized 2.5:1 ratio to maze operation or no maze operation after MV surgery
➢SF-36
➢Significant ↑ QoL post-MV surgery (P<.05)

➢Maze operation post-MV surgery did not ↑ QoL further (P>.05)
➢Highly symptomatic pts.

(c) Internal/external cardioversion and pacing studies
Berry et al (2001)49 UKProspective (12 mo)111 pts. with persistent AF (66.8±11)DC cardioversion
➢EuroQuoL visual analogue scale
➢Significant ↑ in QoL in pts. who remained in SR (+10.3% ± 3.5%; P = .01)
➢No control group

Kale et al 200250 UKProspective (<24 mo)28 pts. with PAF (58)Atrial septal pacemaker implantation
➢Customized QoL questionnaire
➢79% pts. reported some improvement in QoL at follow-up†
➢Highly symptomatic pts.

➢No control group

➢Nonvalidated QoL instrument

Newman et al (2003)51 USAProspective (12 mo and every 6 mo thereafter)173 pts. with AF vs 269 healthy controlsImplanted atrial defibrillator
➢SF-36
➢Baseline QoL significantly ↓ compared with healthy controls (P<.05)

➢Intervention significantly ↑ QoL on 5/8 subscales (P<.05), irrespective of number of shocks applied
➢No control group

➢Highly selected symptomatic pts.

Ricci et al (2004)52 ItalyProspective (15 ± 4 mo)40 pts. with drug-refractory AF (64±10)Dual defibrillator implantation
➢SF-36
➢Significant ↑ QoL after implantation (P<.05)

➢Early delivery of atrial shock led to greater improvement in QoL†
➢No control group

Studies comparing various rhythm-control strategies
(a) Rhythm control vs rhythm control
Dorian et al (2002)53 Canada

CTAF trial

Prospective, randomized (3 and 12 mo)294 pts. with PAF or persistent AF (65±10)50% on amiodarone vs 25% on sotalol vs 25% on propafenone (±DC cardioversion if needed)
➢SF-36
➢Significant ↑ QoL from baseline to 3 mo in all three groups (P<.05)

➢No significant between group differences in QoL (P>.05)

➢No significant changes in QoL between 3- and 12-mo follow-up (P>.05)

➢No significant differences in QoL at 3 mo between those cardioverted or not (P>.05)
Krittayaphong et al (2003)54 BangkokProspective, cross-sectional (12 mo)38 pts. with symptomatic AF (ablation group: 55.3±10.5; drug therapy: 48.6±15.4)15 pts. to radiofrequency catheter ablation therapy of left atrium and PV vs 15 pts. to amiodarone
➢SF-36
➢Significant ↑ QoL in ablation group (P = .007)

➢No improvement in QoL in amiodarone group (P = .86)
➢Small sample size

➢Highly symptomatic pts.

Pappone et al (2003)55 ItalyProspective (12 mo and every 6 mo thereafter)211 pts. with AF (65±10)109 pts. to radiofrequency PV ablation vs 102 pts. to antiarrhythmic drug therapy
➢SF-36
➢Baseline QoL similar in both groups (P>.05)

➢Significant ↑ QoL in ablation group (P<.05); QoL at normative levels by 6 mo (P = .004), no further changes at 1 year (P>.05)

➢Little improvement in QoL in medically treated group over 12 mo†
➢Not randomized to treatment

➢Highly selected symptomatic patients

➢QoL data available on only 18% of total study population

Channer et al (2004)56 UKProspective, randomized, placebo-controlled (12 mo)161 pts. with persistent AF (placebo: 68±8, short-term amiodarone: 65±10, long-term amiodarone: 66±10)
Placebo: Placebo for 2 wk before and 52 wk after successful DC cardioversion

Short-term amiodarone: Amiodarone for 2 wk before and 8 wk after successful DC cardioversion, followed by placebo for 44 wk

Long-term amiodarone: Amiodarone for 2 wk before and 52 wk after successful DC cardioversion
➢SF-36
➢Similar QoL scores in all three groups at baseline† Similar ↑ in QoL in all three groups at 8- and 52-wk follow-ups†
➢Placebo group not sex-matched with two amiodarone groups

AF = atrial fibrillation; AV = atrioventricular; CTAF = Canadian Trial of Atrial Fibrillation; DC = direct current; EuroQoL = EuroQoL visual analogue scale; LHFQ = Living with Heart Failure Questionnaire; MCS = Mental Component Summary score on SF-36; MV = mitral valve; PAF = paroxysmal atrial fibrillation; PGWB = Psychological General Well-Being; pts. = patients; PCS = Physical Component Summary score on SF-36; PV = pulmonary vein; QoL = quality of life; SD = standard deviation; SF-36 = Medical Outcome Survey Short Form-36; SR = sinus rhythm; ↑ = increased; ↓ = decreased; < =less than; > = greater than;

† P value not reported.

Table 4. Summary of Studies Examining the Effect of Rate Versus Rhythm Control on Quality of Life in Patients with Atrial Fibrillation
Author, Year, PlaceStudy Design (follow-up period)Participants (mean ± SD age, y)InterventionMeasure of Quality of LifeResultsStudy Limitations
(a) Pharmacologic rate control ± AV node ablation vs cardioversion (DC or pharmacologic) ± pharmacologic rhythm control
Carlson et al (2003)11 GermanyProspective, randomized (36 mo)200 pts. with persistent AFRate: beta-blockers, digitalis, calcium antagonists
➢SF-36
➢Significant ↓ QoL in pts. with AF compared with healthy age-matched controls in SR (from previous research) (P<.01)
➢Two groups not sex-matched

➢Poorer QoL baseline scores in rate-control group

➢No placebo group

STAF trial Rhythm: Serial cardioversion, antiarrhythmic drugs, or beta-blocker
➢Significant ↑ in 2/8 subscales in rhythm-control group (P<.05) vs 5/8 in rate-control group (P<.05)
Gronefeld et al (2003)12 GermanyProspective randomized (12 mo)252 pts. with persistent AF (60.5)Rate:Pharmacologic ventricular rate control or AV node ablation
➢SF-36
➢No significant differences in baseline QoL between rate and rhythm group (P>.05)
➢Significantly more pts. in rhythm-control arm were newly diagnosed

➢No placebo group

PIAF trial Rhythm: Pharmacologic or electrical cardioversion
➢Significant ↓ QoL in pts. with AF compared with healthy individuals (P<.05) Significant ↑ in 6/8 and 5/8 QoL domains for rate (P<.05) and rhythm-control group (P<.05), respectively
Hagens et al (2004)13 The Netherlands

RACE trial

Prospective, randomized (36 mo)352 pts. with persistent AF (68±9)
Rate: Rate-controlling drugs and oral anticoagulation

Rhythm: Serial DC cardioversion, antiarrhythmic drugs and oral anticoagulation
➢SF-36
➢Significant ↓ QoL in pts. with AF at baseline compared with healthy controls (P<.05), but similar for rhythm and rate control (P>.05)

➢Rate-control group ↑ significantly in 3/8 domains (role physical, mental health, and social functioning; P<.05)

➢Rhythm-control group showed significant improvement in any QoL domain (P>.05)
➢Two groups were not sex-matched

➢No placebo group

Vora et al. (2004)57 IndiaCross-sectional (12 mo)144 pts. with chronic AF (38.6±10.3)
Rate: 48 pts. randomized to receive 90 mg of diltiazem twice daily to maintain resting ventricular rate <130 beats/min

Rhythm: 48 pts. to amiodarone

Control: 48 pts. to placebo
➢Unspecified QoL instrument
➢Significantly greater ↑ in QoL in rhythm-control group than rate-control group†

➢Subgroup analysis revealed that whether or not the pts. remained in SR at follow-up predicted QoL†
➢Nonspecified/nonvalidated QoL instrument

➢Very young AF group

Jenkins et al (2005)14 USA

AFFIRM trial

Prospective, randomized (72 mo)716 pts. with PAF and chronic AF (70±9)
Rate: Rate-controlling drugs and oral anticoagulation

Rhythm: Serial DC cardioversion, antiarrhythmic drugs and oral anticoagulation
➢SF-36 QoL Index (Cardiac Version) Cantril Ladder of Life
➢QoL was similar in both treatment groups at baseline (P>.05)

➢Significant ↑ in QoL from baseline to follow-up in both groups (P<.05)

➢Similar ↑ in QoL for both groups (P>.05)
(b) AV node/junction and bundle of HIS ablation ± pacing vs pharmacologic therapy
Brignole et al (1997)58 ItalyProspective, randomized (6 mo)43 severely symptomatic pts. with PAF (ablation group: 66±10, medical group: 64±10)
Rate: 22 pts. to AV junction ablation and pacing

Rhythm: 21 pts. to antiarrhythmic drug therapy
➢Minnesota LHFQ
➢Significantly greater ↑ in QoL and ↓ in symptoms in ablate and pace group (50 ± 19 to 20 ± 16; P<.0001) compared with antiarrhythmic group (50 ± 19 to 43 ± 22; P = .0006)
➢Highly selected symptomatic pts.

➢Heart failure-specific QoL instrument employed

Marshall et al (1999)59 UKProspective, randomized (18 wk)56 symptomatic pts. with PAF (ablate and pace group: 65 2±7.5, medical group: 60.3±9.8)
Rate: 37 pts. to AV junction ablation and pacemaker implantation

Rhythm: 19 pts. to medical therapy
➢PGWB questionnaire

➢McMaster Health Index
➢Similar baseline scores on PGWB questionnaire and McMaster Health index (P>.05)

➢Significant ↑ in QoL in ablate and pace group from baseline to 18 wk (PGWB: 68.8±18.1 to 77.4±21.6; P<.05 and MHI: 14.8 ± 3.3 to 16.1 ± 3.2; P<.05)

➢No change in QoL for medical therapy group from baseline to 18 wk (PGWB: 69.48 ± 14.3 to 68.5 ± 13.6; P>.05 and MHI: 15.5 ± 3.7 to 15.7 ± 3.0; P.05)
➢Highly selected and symptomatic pts.

Ueng et al (2001)60 TaiwanProspective, cross-sectional (12 mo)50 pts. with chronic lone AF (ablation group: 68 ± 6, medical group: 65 ± 8)
Rate: 21 pts. to radiofrequency catheter ablation of AV junction and pacemaker implantation

Rhythm: 29 pts. to medical therapy
➢Detailed QoL diary
➢Medically treated showed no change in QoL (2.7 ± 0.6 to 2.8 ± 0.7; P>.05)

➢Significant ↑in QoL in ablate and pace group (2.8 ± 0.6 to 2.1 ± 0.5; P<.05)
➢Nonvalidated QoL instrument

➢Pts. not randomized to treatment

AF = atrial fibrillation; AFFIRM = Atrial Fibrillation Follow-up Investigation of Rhythm Management; AV = atrioventricular; AF = atrial fibrillation; DC = direct current; LHFQ = Living with Heart Failure Questionnaire; MHI = McMaster Health Index; PAF = paroxysmal atrial fibrillation; PGWB = Psychological General Well-Being; PIAF = Pharmacologic Intervention in Atrial Fibrillation trial; pts. = patients; QoL = quality of life; RACE = RAte Control versus Electrical cardioversion trial; SD = standard deviation; SF-36 = Medical Outcome Short Form-36; SR = sinus rhythm; STAF = Strategies of Treatment of Atrial Fibrillation; ↑ = increased; ↓ = decreased; < =less than; > = greater than;

† P value not reported.

Noninterventional Observational Studies Examining Quality of Life in Patients with Atrial Fibrillation 

Five observational studies16, 17, 18, 19, 20 examined QoL using the Short Form (SF)-36 in a “general” population with AF, comprising patients with paroxysmal AF and chronic AF, in addition to elderly patients and patients with newly diagnosed AF (Table 1). Four of these studies16, 18, 19, 20 compared patients with AF with a control group: other patients with coronary heart disease,16 general population,20 and healthy controls.16, 18, 19 Three of these studies16, 18, 19 reported a poorer QoL in patients with AF on some18, 19 or all of the SF-36 subscales.16 One study17 comparing the QoL of male and female patients with AF revealed that women reported significantly poorer physical and functional health, although mental health and well-being scores were virtually identical for men and women.

Effect of Rate-Control Strategies on Quality of Life in Patients with Atrial Fibrillation 

Six studies21, 22, 23, 24, 25, 26 examined the effect of atrioventricular (AV) node/junction and bundle of HIS ablation and pace procedures in paroxysmal AF and persistent and chronic AF. All of these studies demonstrated a significant improvement in QoL over the postintervention follow-up periods, which ranged from 6 weeks to 12 months (Table 2).

Ten studies24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 evaluated the effects of various rate-control strategies on QoL in patients with AF; 8 studies compared AV node/junction ablation and pacing27, 28, 29, 30, 31, 32, 33, 34 with AV modification,28, 29 various modalities of pacing,27, 28, 29, 30, 31, 32, 33 versus30 or with the addition of pharmacologic therapy postintervention,30, 31, 32 and 2 studies35, 36 compared ventricular rate control with drugs35 or pacing.36 Two studies28, 29 examining the effect of AV node ablation and pacing versus AV node modification reported significant improvement in QoL in the ablate and pace group. The benefit of AV node modification on QoL is equivocal, with 1 study reporting no change in QoL for patients who had successful AV node modification,29 and the other reporting significant improvement.28

Permanent destruction of the AV node/junction and synchronous dual-chamber/single-chamber ventricular pacing is another rate-control strategy in the management of refractory AF. Two studies27, 33 examined the effect of various pacing strategies after ablation on QoL. Both single-chamber pacing in chronic AF and dual-chamber pacing in patients with paroxysmal AF after ablation provided similar significant improvements in QoL27 irrespective of whether rate responsive pacing was turned on or off.33 The remaining 4 studies30, 31, 32, 34 examined the effect of pharmacologic rate-control therapy, in addition to30, 31, 32 and in comparison with34 ablate or pace procedures. Two studies demonstrated that adjunctive pharmacologic therapy confers no additional benefit for QoL over and above ablate and pace procedures alone.31, 33 However, Weerasooriya and colleagues34 suggest that pharmacologic rate control alone was as efficacious as AV junction ablation and pacing alone in improving QoL. Two studies comparing the effect of pacing and pharmacologic therapy, with ablation and pacing with or without drug therapy, also provided conflicting results. One study found similar improvements in QoL under both rate-control regimens,31 whereas the other demonstrated no improvement in QoL in the group undergoing pacing with the addition of drug therapy.30 The final 2 studies,35, 36 examining the effects of ventricular rate-control drugs35 and pacing (without ablation) with or without ventricular response pacing,36 reported no significant differences in QoL between groups after treatment.

Effect of Rhythm-Control Strategies on Quality of Life in Patients with Atrial Fibrillation 

Fourteen studies examined the effect of rhythm-control strategies alone on QoL in patients with AF using a number of different methods, including percutaneous37, 38, 39, 40, 41, 42, 43, 44, 45 or surgical46, 47, 48 interventions, or internal/external cardioversion49, 51, 52 and pacing50 (Table 3). Of the 9 percutaneous intervention studies, 5 used radiofrequency catheter ablation of atrial foci,37, 39, 42, 45 and 440, 41, 43, 44, 45, 46 used PV isolation as rhythm-control strategies for AF. All 9 studies37, 38, 39, 40, 41, 42, 43, 44, 45 assessing QoL with the SF-36 demonstrated significant improvements in QoL among these highly symptomatic patients after the intervention. Even unsuccessful PV isolation led to increased QoL on one-half of the SF-36 subscales.45

Three studies46, 47, 48 examined the impact of the Maze operation on QoL, 1 after mitral valve surgery.48 QoL, again assessed by the SF-36, was significantly improved after the intervention,46, 47, 48 with patients with AF reporting QoL scores similar to those of the general population.47 However, the Maze operation, in addition to mitral valve surgery, did not afford any additional enhancement in QoL compared with mitral valve surgery alone.48

Few studies49, 50, 51, 52 examined the effect of cardioversion, atrial pacing, or defibrillation as rhythm-control strategies on the QoL of patients with AF. QoL is significantly improved among patients who have undergone direct current (DC) cardioversion and remain in sinus rhythm,49 patients with an implanted atrial defibrillator51, 52 (irrespective of the number of shocks applied51), and patients with an implanted atrial septal pacemaker.50

Only 4 studies53, 54, 55, 56 to date have compared the effects of 254, 55 or more53, 56 different rhythm-control strategies on QoL. Two of these studies,54, 55 comparing radiofrequency PV ablation with antiarrhythmic drug therapy, revealed a better QoL in patients receiving ablation, with little improvement in QoL among patients treated pharmacologically. Of the other 2 studies,53, 56 1 compared the effects of short-term (8 weeks) and long-term (52 weeks) amiodarone therapy after successful DC cardioversion with placebo and demonstrated a similar improvement in QoL in all 3 groups during the first year,56 and 1 compared the effects of amiodarone, sotalol, or propafenone (with or without DC cardioversion) and found significant improvements in QoL in all 3 groups, but only for the first 3 months of follow-up.53

Effect of Rate Versus Rhythm-Control Strategies on Quality of Life in Patients with Atrial Fibrillation 

Eight studies examined the effect of rate-control versus rhythm-control strategies on QoL in patients with AF11, 12, 13, 14, 57, 58, 59, 60 (Table 4). Five studies,11, 12, 13, 14, 57 including 4 large randomized trials (STAF,11 PIAF,12 RACE,13 and AFFIRM14) compared pharmacologic rate control with or without AV node ablation with cardioversion (DC or pharmacologic) with or without pharmacologic rhythm control. All reported an improvement in QoL after intervention. Of the 4 randomized trials, 311, 12, 13 demonstrated a greater improvement in QoL, assessed using the SF-36, among patients receiving rate-control treatment. However, the AFFIRM trial14 revealed that the improvement in QoL after intervention was similar for both rate and rhythm-control strategies. The other study57 comparing rate and rhythm strategies demonstrated that there was a significantly greater improvement in QoL among patients in the rhythm-control group. However, this study used a nonvalidated measure of QoL in an uncharacteristically young population with AF, and therefore caution is warranted in interpreting these results.

Three studies58, 59, 60 compared AV node/junction ablation with or without pacing with pharmacologic therapy. All 3 studies, using a variety of QoL assessments, demonstrated a significant increase in QoL in patients with AF undergoing rate-control intervention compared with rhythm-control treatment.58, 59, 60

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Discussion 

Patients with AF have significantly poorer QoL compared with healthy controls,11, 12, 13, 16, 18, 19, 51 the general population,20, 38, 47 and other patients with coronary heart disease.16 The majority of studies examining QoL in patients with AF focused on highly selected and symptomatic patients undergoing interventions such as ablate and pace procedures,21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 the Maze operation,46, 47, 48 PV isolation,40, 41, 43, 44 internal or external cardioversion,49, 50, 51, 52 different pacing modalities,27, 33, 36 or pharmacologic therapy (either alone31, 35 or in combination30, 31, 32), with only 5 studies16, 17, 18, 19, 20 examining QoL in what one would term a “general” population with AF. Most of these interventional studies demonstrated an improvement in QoL, with 3 of the 4 randomized control trials (STAF, PIAF, RACE)11, 12, 13 comparing rate versus rhythm control reporting that rate control is superior to rhythm control in improving QoL. However, the AFFIRM trial found no difference in QoL between rate and rhythm-control strategies.14

General Patients with Atrial Fibrillation 

It has been suggested that ventricular rate and the predictability of a patient’s clinical treatment may be independent contributors to QoL, whereby patients with better-controlled heart rates and a more predictable clinical course display lower levels of QoL impairment.18 This may explain the poorer QoL exhibited by patients with paroxysmal AF in comparison with patients with permanent AF, because patients with permanent AF tend to have a relatively predictable course of treatment, with rate-controlled drugs and more “stable” heart rates compared with patients with paroxysmal AF. However, a recent study demonstrated that there was no significant association between achieved heart rate either at rest or during exercise and QoL in the AFFIRM study.61

Ablate and Pace Procedures 

It seems that the type of intervention used to control the heart rate or rhythm determines whether, and to what extent, QoL is enhanced. Rate control, using radiofrequency catheter AV node/junction and bundle of His ablation and pacing alone,21, 22, 23, 24, 25, 26 in combination or comparison with other rate-control strategies,27, 28, 29, 30, 31, 32, 33, 34 has been the major area of interest with regard to examining the effect of rate-control strategies on QoL in patients with AF. It seems to, in agreement with Wood and colleagues,62 significantly improve QoL. Adjunctive pharmacologic therapy has no added benefit over ablate and pace procedures alone on QoL,30, 31, 32 and all modalities of pacing seem to be efficacious to QoL.27, 33 The huge symptomatic relief after ablation and pacing treatment may explain these findings. Few studies have examined the effects on QoL of rate-control pacing and drug therapy in combination, and the available data are conflicting.30, 31, 32

Different Pacing Modalities 

Few studies have examined the effect of different pacing modalities (without ablation) on patients with AF, particularly the impact of such interventions on QoL. Although pooled analyses demonstrate a significant reduction in AF and pacemaker syndrome with dual-chamber pacing in patients with sick sinus syndrome and AV block,63 the data on QoL are equivocal. The only study to date that has assessed VVIR or DDDR with or without ventricular response pacing in patients with AF exclusively demonstrated no significant differences in QoL between those receiving and not receiving ventricular response pacing.36

Pulmonary Vein Isolation 

During the last 5 years a number of studies have reported the effects of new rhythm-control strategies, such as catheter ablation of atrial foci,37, 38, 39, 42 PV isolation,39, 40, 41, 43, 44 and the Maze operation,46, 47, 48 on QoL in patients with AF. All of these studies37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48 reported a significant improvement in QoL after intervention, again presumably reflecting immediate relief of symptoms. In addition, only 2 studies54, 55 to date have compared one of these newer rhythm-control strategies with other types of rhythm control. Studies comparing PV isolation with rhythm-controlling drug therapy demonstrated significant improvement in the PV isolation group, with little improvement in the pharmacologically treated group.54, 55 However, these results should be treated with caution because of the small sample sizes and failure to randomize patients to the treatment arms.54, 55

Rate Versus Rhythm Control 

Eight studies to date have compared rate versus rhythm control on QoL in patients with AF.11, 12, 13, 14, 57, 58, 59, 60 The 5 studies11, 12, 13, 14, 57 using pharmacologic rate control, with or without AV node ablation, versus cardioversion (DC or pharmacologic), with or without pharmacologic rhythm control, all demonstrated significant improvements in QoL after the various interventions. Three of the major randomized trials (STAF,11 PIAF,12 and RACE13) reported significantly better QoL in patients with AF randomized to receive rate-control interventions. However, the AFFIRM trial,14 the largest study to date and properly powered to examine QoL as an outcome, reported similar improvements in QoL for both the rate and rhythm-control groups. The reduced improvement in patients receiving rhythm control in three of the four major trials may be explained by a lower efficacy of current pharmacologic therapy for rhythm control in AF. In contrast, rate control is easier to achieve, and therefore it is plausible that new antiarrhythmic or nonpharmacologic therapy may demonstrate greater efficacy and prove to be superior to rate control. Further, the 3 studies comparing AV node/junction and bundle of His ablation, with or without pacing, versus pharmacologic rhythm control also reported significant improvements in QoL among patients with AF undergoing rate control, with little change evident in the rhythm-control group.14, 58, 59, 60 However, the patients in the rhythm-control group did not experience a reduction in symptoms,60 which may explain why there was no change in QoL.

Methodologic Weaknesses 

Although using a variety of different QoL measures and different types of rate and rhythm-control interventions, these studies demonstrated a significant improvement in QoL among highly symptomatic patients after intervention. However, many of the studies have a range of methodologic weaknesses, including small sample size,18, 19, 20, 21, 22, 24, 25, 26, 31, 35, 46, 51 no control group,16, 17, 18, 19, 20, 21, 22, 23, 24, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52 short-term follow-up periods (<6 months),21, 25, 36 and use of nonvalidated tools to assess QoL.27, 28, 50, 60 Also, many of the studies assessing QoL were performed on a subgroup of a larger cohort of clinical trial patients and may not have been powered for such analyses. For these reasons, we have not performed a meta-analysis, because the results may be misleading.

Although the results of these studies should be treated with caution, it seems that interventions for AF significantly improve QoL, although rate-control strategies seem to be slightly superior to rhythm control in the majority of studies.11, 12, 13, 58, 59, 60 Many reasons have been postulated for the dramatic improvement in QoL, including the large and rapid decrease in the frequency and severity of arrhythmia-related symptoms, cessation of antiarrhythmic drugs and their concomitant side effects, exaggerated baseline scores caused by anxiety associated with undergoing an invasive procedure,61 uncertainty about the course of clinical treatment, and an increase in patient satisfaction solely through being part of treatment group (Hawthorne effect).21

Future larger randomized studies of QoL among a more “general” population with AF are needed, rather than focusing on highly selected symptomatic patients with AF. In addition to using appropriate control groups, such studies should compare “newer” and more traditional rhythm-control strategies with each other and with rate-control strategies to determine which is the best treatment option in terms of not only morbidity and mortality but also QoL.64

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PII: S0002-9343(05)01067-3

doi:10.1016/j.amjmed.2005.10.057

The American Journal of Medicine
Volume 119, Issue 5 , Pages 448.e1-448.e19, May 2006

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