Depression screening in AF Clinics recommended by study

Electrophysiologists (EPs) rate the quality of life of patients with Paroxysmal atrial fibrillation (AF) significantly better than the patients themselves do, with the greatest level of disagreement about mental health. The abstract study, presented at the EHRA EUROPACE meeting, 23 to 26 June, in Athens, Greece, found that patients with paroxysmal AF, even in the absence of significant concomitant cardiac disease, showed signs of depression, sleeping disorders and low levels of physical activity.

Since neither rate or rhythm control strategies for AF have been shown to be superior to the other in survival or stroke outcomes, decisions need to be made about which approach is better for each patient's long-term management.

"EPs generally decide whether to take a more or less aggressive treatment approach according to the patient's disease burden. Here, not only physical symptoms need to be taken into consideration, but also the patient's mental health and quality of life in general. If EPs don't know that their patients are suffering from depression they may not be offering them optimum treatments," says Professor Karl Ladwig, the first author of the study. "Good communication between physicians and patients is of paramount importance for adherence to medications and long term prognosis."

In the current study, Ladwig and colleagues set out to assess the degree of congruence between patient and physician assessment of the patients' subjective health status, which, the authors say, provides a good indicator of patient-physician communication and shared understanding. Data for the analysis was taken for patients enrolled in the Angiotensin II Antagonist in Paroxysmal Atrial Fibrillation (ANTIPAF) trial. The ANTIPAF trial, conducted by Professor Andreas Goette within the German Competence NETwork on Atrial Fibrillation (AFNET), examined whether angiotensin II receptor blockers reduced the incidence of paroxysmal AF. The analysis also specifically explored discordance between AF patients and their doctors.

Between February 2004 and September 2008, 334 patients (41% female and 59% male) with paroxysmal AF, without significant concomitant heart disease, and their physicians from 43 participating centres were asked to rate the patients' heath related quality of life (HRQoL). Patients filled in the SF-12 self rating scale in the clinic or home; while physicians complete the SF8 scale after the patient had left the clinic. Physicians had no access to the patient's answer sheets.

Intra-Class Correlations (ICC) were used to assess the consistency or conformity of the measures made by multiple observers, and Bland Altman graphs plotted the strength of concordance for each patient against average ratings for both physicians and patients.

Results show physicians rated their patients' health-related quality of life higher than patients, both for the mental component score (P<0.0001) and physical component score (p=0.001). Both the ICCs and Bland-Altman graphs showed unsatisfactory concordance. In the regression analyses, depression was significantly associated with discord in the mental component score (ß=-0.94; p<0.001) and the physical component score (ß=-4.13; p<0.002). Furthermore, sleeping disorders were associated with discord in the mental component score (ß=-4.13; p<0.002) and physical activity with discord in the physical component score (ß=-1.47; p=0.006).

"When one considers the importance placed on quality of life in the AF literature these levels of discordance between physicians and patients are surprisingly large. They underline the need for physician to be trained to recognize depression in patients and for the introduction of systematic screening for depression in all AF clinics," says Ladwig, from the Helmholtz Centre, Munich, Germany.

Future studies should explore whether interventions such as physician training and screening, improve both quality of life and the underlying disease status of patients with AF, he said.