A Randomised Controlled Trial on the Effect of Nurse-Led Educational Intervention at the Time of Catheter Ablation for Atrial Fibrillation on Quality of Life, Symptom Severity and Rehospitalisation

Abstract

Atrial Fibrillation (AF) is a common condition associated with impaired quality of life (QOL) and recurrent hospitalisation. Catheter ablation for AF is a well-established treatment for symptomatic patients despite medical therapy. We sought to examine the effect of point specific nurse-led education on QOL, AF symptomatology and readmission rate post AF ablation.

Forty-one patients undergoing AF ablation were randomised to Nurse Intervention (NI) versus Control (C), n=22 vs. 19. Both groups were well matched with respect to age, sex and AF subtype. All patients completed SF36 and AF Symptom Checklist, Frequency and Severity Scale questionnaires at baseline and six months post ablation. The NI group underwent nurse education on admission, prior to discharge, and with telephone contact.

Baseline SF-36 and AF Symptom Checklist, Frequency and Severity scores were similar. The NI group showed significant differences compared to Control with respect to higher QOL on the SF-36 score of Physical Functioning and Vitality at six months. There were significant improvements in seven components of the AF Symptom Checklist, Frequency and Severity at six months in the NI group with a trend in a further seven. There was no difference in AF related hospital readmissions at six months between C and NI groups (10.5% vs. 13.6%, p=ns).

Nurse-led education at time of AF ablation is associated with improved QOL and reduced symptom frequency and severity compared to usual care.

Full text

A
Randomised
Controlled
Trial
on
the
Effect
of
Nurse-Led
Educational
Intervention
at
the
Time
of
Catheter
Ablation
for
Atrial
Fibrillation
on
Quality
of
Life,
Symptom
Severity
and
Rehospitalisation
John
L.
Bowyer,
RN
a
,
Phillip
J.
Tully,
PhD
a,b
,
Anand
N.
Ganesan,
PhD
a,b
,
Fahd
K.
Chahadi,
MBBS
a
,
Cameron
B.
Singleton,
MD
a
,
Andrew
D.
McGavigan,
MD
a,b*
a
Department
of
Cardiovascular
Medicine,
Flinders
Medical
Centre,
Adelaide,
SA,
Australia
b
Faculty
of
Medicine,
Flinders
University,
Adelaide,
SA,
Australia
Received
2
March
2016;
received
in
revised
form
12
April
2016;
accepted
23
April
2016;
online
published-ahead-of-print
14
June
2016
Background
Atrial
Fibrillation
(AF)
is
a
common
condition
associated
with
impaired
quality
of
life
(QOL)
and
recurrent
hospitalisation.
Catheter
ablation
for
AF
is
a
well-established
treatment
for
symptomatic
patients
despite
medical
therapy.
We
sought
to
examine
the
effect
of
point
specific
nurse-led
education
on
QOL,
AF
symptomatology
and
readmission
rate
post
AF
ablation.
Methods
Forty-one
patients
undergoing
AF
ablation
were
randomised
to
Nurse
Intervention
(NI)
versus
Control
(C),
n=22
vs.
19.
Both
groups
were
well
matched
with
respect
to
age,
sex
and
AF
subtype.
All
patients
completed
SF36
and
AF
Symptom
Checklist,
Frequency
and
Severity
Scale
questionnaires
at
baseline
and
six
months
post
ablation.
The
NI
group
underwent
nurse
education
on
admission,
prior
to
discharge,
and
with
tele-
phone
contact.
Results
Baseline
SF-36
and
AF
Symptom
Checklist,
Frequency
and
Severity
scores
were
similar.
The
NI
group
showed
significant
differences
compared
to
Control
with
respect
to
higher
QOL
on
the
SF-36
score
of
Physical
Functioning
and
Vitality
at
six
months.
There
were
significant
improvements
in
seven
components
of
the
AF
Symptom
Checklist,
Frequency
and
Severity
at
six
months
in
the
NI
group
with
a
trend
in
a
further
seven.
There
was
no
difference
in
AF
related
hospital
readmissions
at
six
months
between
C
and
NI
groups
(10.5%
vs.
13.6%,
p=ns).
Conclusion
Nurse-led
education
at
time
of
AF
ablation
is
associated
with
improved
QOL
and
reduced
symptom
frequency
and
severity
compared
to
usual
care.
Keywords Ablation Catheter
Ablation Trials
©
2016
Australian
and
New
Zealand
Society
of
Cardiac
and
Thoracic
Surgeons
(ANZSCTS)
and
the
Cardiac
Society
of
Australia
and
New
Zealand
(CSANZ).
Published
by
Elsevier
B.V.
All
rights
reserved.
*Corresponding
author
at:
Dept
of
Cardiovascular
Medicine
Bedford
Park,
South
Australia
5042,
Australia,
Tel.:
8
8204
5619;
fax:
8
8204
5625,
Email:
Andrew.McGavigan@health.sa.gov.au
Heart,
Lung
and
Circulation
(2017)
26,
73–81
1443-9506/04/$36.00
http://dx.doi.org/10.1016/j.hlc.2016.04.024
ORIGINAL
ARTICLE
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Introduction
Atrial
Fibrillation
(AF)
is
the
most
common
heart
rhythm
disorder[1,2]
with
an
overall
prevalence
in
the
general
pop-
ulation
of
2%,
rising
to
over
8%
in
those
aged
75
and
older[3].
There
has
been
a
progressive
increase
in
AF
incidence
and
prevalence
in
the
last
30
years[2]
and,
with
an
expanding
ageing
population,
the
prevalence
is
expected
to
significantly
increase
in
the
coming
decades
across
the
US[4],
Europe[5]
and
the
Asia-Pacific
region[6,7].
In
addition
to
increased
risk
of
stroke
and
death[8,9],
atrial
fibrillation
is
characterised
by
a
myriad
of
symptoms
includ-
ing
shortness
of
breath,
fatigue,
chest
pain,
palpitations
and
dizziness
which
are
associated
with
impaired
quality
of
life
(QOL),
anxiety
and
depression[10–14],
which
in
turn
adversely
impact
on
self-reported
AF
symptom
severity
[13,15,16].
Catheter
ablation
is
a
well-established
treatment
for
AF,
and
is
currently
a
Class
I
indication
for
drug
refractory
symp-
tomatic
paroxysmal
AF
and
a
Class
IIa
indication
for
persis-
tent
AF[17,18].
It
is
associated
with
improvement
in
QOL
compared
to
anti-arrhythmic
drug
therapy[19,20].
However,
impaired
QOL
remains
common
and
baseline
indices
of
QOL
are
associated
with
recurrence
of
symptoms
post
ablation[21].
Nurse-directed
education,
counselling
and
intervention
has
proven
to
be
an
effective
tool
in
improving
quality
of
life,
reducing
anxiety
and
improving
outcome
in
patients
with
many
chronic
diseases
including
heart
failure[22,23],
ischaemic
heart
disease[24,25]
and
renal
failure[26,27].
With
regards
to
atrial
fibrillation,
there
are
emerging
data
support-
ing
the
role
of
nurse
education
and
counselling
in
patients
with
AF
in
the
outpatient
setting[28,29]
and
more
recently
as
part
of
an
integrated
multi-disciplinary
approach
following
hospitalisation[30].
These
all
require
ongoing
nurse
interven-
tion
over
time.
However,
there
are
also
data
to
support
a
single
or
limited
time
point
intervention
of
nurse-directed
education
prior
to
cardiac
surgery[31,32],
but
no
data
are
available
on
its
effect
in
patients
undergoing
catheter
ablation
for
atrial
fibrillation.
We
therefore
performed
a
small,
randomised
controlled
trial
to
examine
the
hypothesis
that
nurse-led
educational
intervention
at
the
time
of
radiofrequency
ablation
for
atrial
fibrillation
would
have
a
positive
effect
on
symptomatology,
QOL
and
readmission
rate
in
the
six
months
following
the
procedure.
Methods
This
study
was
approved
by
the
institutional
ethics
commit-
tee
and
all
participants
provided
written
informed
consent.
The
study
design
is
outlined
in
Figure
1.
Figure
1
CONSORT
diagram
of
study
design.
74
J.L.
Bowyer
et
al.
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Consecutive
patients
undergoing
first
elective
catheter
ablation
for
drug
refractory
atrial
fibrillation
at
Flinders
Medical
Centre
were
identified
and
invited
to
participate
in
the
study.
Patients
who
had
undergone
any
previous
form
of
ablation
were
excluded.
Patients
were
randomised
prior
to
ablation
by
random
number
generator
to
receive
nurse
intervention
(NI)
plus
standard
physician
care
or
standard
physician
care
alone
(Control).
Randomisation
was
performed
with
opaque
sealed
envelopes
and
concealed
from
staff.
The
interven-
tional
electrophysiologist
and
follow-up
physician
were
blinded
to
the
study
arm
in
all
phases
of
the
study.
The
AF
ablation
procedures
were
performed
in
a
standard
manner
under
general
anaesthesia
using
a
three-dimensional
(3D)
mapping
system
(St
Jude
Medical,
St
Paul,
MN,
USA).
The
strategy
employed
was
antral
isolation
of
all
pulmonary
veins
with
exit
block
for
patients
with
paroxysmal
AF.
Linear
ablation
across
the
roof
of
the
left
atrium
with
confirmation
of
block
was
added
for
patients
with
non-paroxysmal
AF.
Nurse
Intervention
The
intervention
in
the
NI
arm
consisted
of
education
per-
formed
by
a
nurse
experienced
in
arrhythmia
management
and
interventional
electrophysiology
at
five
pre-specified
time
points:
face-to-face
on
admission
and
prior
to
discharge
(30
minute
duration),
and
telephone
calls
at
two
weeks,
one
month
and
three
months
post-procedure.
Pre-procedural
education
was
performed
in
a
structured
manner
utilising
the
following
pre-specified
subheadings:
‘‘How
the
heart
works’’;
‘‘AF
causes
and
risk
factors’’;
‘‘AF
symptoms’’;
‘‘Goals
of
treatment
in
atrial
fibrillation’’;
‘‘Procedural
review’’;
and
‘‘Lifestyle
modification’’
(Figure
2).
The
tech-
nique
involved
was
discussion
of
major
subheadings
in
a
standard
fashion,
with
further
discussion
as
required
directed
by
the
patient.
Partner
questions
and
concerns
were
also
addressed.
These
headings
were
also
used
to
direct
the
face-to-face
intervention
prior
to
discharge.
Telephone
calls
at
the
three
time
points
lasted
5-10
minutes
and
concentrated
on
patient
symptoms,
questions
on
drug
therapies
and
life-
style
review
and
were
largely
driven
by
patient
questions/
comments.
Patients
were
also
encouraged
to
phone
with
any
further
concerns
outside
of
the
designated
times
within
the
first
three
months.
No
contact
with
the
nurse
occurred
after
three
months.
Patients
in
both
arms
received
standard
usual
care
but
there
was
no
formalised,
external
structured
educa-
tional
aspect
in
the
Control
arm,
with
education
being
pro-
vided
by
their
treating
cardiologist
and
electrophysiologist
as
per
usual
care.
Study
Endpoints
Primary
The
primary
endpoint
was
determined
as
the
between-group
differences
in
AF
symptom
severity
and
frequency
at
six-
month
follow-up
compared
to
baseline,
measured
by
the
AF
Symptom
Checklist,
Frequency
and
Severity
scale
which
is
a
disease-specific
measure
of
QOL
in
AF[33].
It
is
a
self-
reported
questionnaire
on
the
frequency
and
severity
for
each
of
16
AF
symptoms
(e.g.
‘‘heart
fluttering/skipping’’,
‘‘lightheadedness/dizziness’’).
Respondents
to
the
checklist
assign
numerical
values
to
symptom
frequency
on
a
Likert
scale
from
‘‘Never
=
0’’
to
‘‘Always
=
4.’’
Symptom
frequency
scores
range
from
0
to
64
with
higher
scores
representing
greater
frequency.
Respondents
to
the
checklist
contemporaneously
assign
numerical
values
to
each
of
the
symptoms
experienced
in
regards
to
severity
using
a
Likert
scale
from
‘‘Mild
=
1’’
to
‘‘Extreme
=
3’’.
Scores
range
from
0
if
no
symptoms
listed
are
experienced,
to
48.
Higher
scores
on
this
scale
represent
greater
symptom
severity[34,35].
Secondary
The
principal
secondary
endpoint
was
between-group
differ-
ences
in
QOL
at
six-month
follow-up
compared
to
baseline
determined
with
the
SF36
survey.
The
Short-Form
36
General
Health
Survey
(SF-36)
is
a
generic
QOL
scale
with
minimal
overlap
with
AF
Symptom
Checklist,
Frequency
and
Severity
domains[36].
It
consists
of
36
individual
items
and
is
grouped
into
eight
scales:
physical
functioning,
social
functioning,
role
limitations
caused
by
physical
problems,
role
limitations
caused
by
emotional
problems,
mental
health,
energy/vital-
ity,
bodily
pain,
and
general
health,
and
a
single
item
con-
cerning
health
change.
These
broad
dimensions
are
consistent
with
the
recommendations
of
the
World
Health
Organization
for
a
generic
HRQOL
instrument[37].
The
indi-
vidual
items
that
comprise
each
of
the
eight
quality
of
life
QOL
domains
measured
by
the
SF-36
were
summed
and
transformed
in
the
prescribed
fashion[36].
Each
SF-36
scale
1. How the heart works
a. Normal heart function and anatomy
– use of model
b. Electrical supply of
the heart
– generation
of
heart
beat,
role
of
sino-atrial and atrioventricular node
c. Role of the atrium in normal heartbeat
d. What
happens in
AF
–loss
of
atrial
transport,
irregular
ventricular rate
2. AF causes and risk factors
a. Risk factors with are not modifiable
– genetics, age
b. Risk factors
which
are modifiable
– weight,
sleep apn
oea,
hypertension, diabetes
3. AF symptoms
a. Types of AF –
paroxysmal vs. persistent
b. Palpitations, dyspn
oea, poor exercise tolerance
c. Anxiety, fear
d. What to expect during an AF episode
e. When to seek help
4. Goals of treatment
a. Prevention of
stroke
– risk
factors
(CHADS2)
and
role
of
oral
anticoagulation
b. Symptom improvement – rationale for rhythm control strategy
5. Procedural review
a. Utilisation
of a model to outline lesion set
b. Discussion of
what to
expect
in
the
EP
lab
and post
-procedural
period
c. Expectations of recovery time and return to normal activities
d. Importance of continuance of medications
6. Lifestyle modification
a. Importance of weight reduction, exercise, healthy eating
b. Alcohol reduction
Figure
2
Structured
education:
Areas
for
discussion.
Nurse-led
educational
intervention
in
AF
ablation
75
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has
a
mean
of
50
and
a
SD
of
10,
and
higher
scores
indicate
improved
QOL.
The
SF36
is
one
of
the
most
commonly
utilised
measures
for
generic
health-related
QOL
with
higher
scores
associated
with
improved
QOL.
It
has
been
endorsed
as
a
reliable,
valid
and
sensitive
measure
of
cardiac
patients’
QOL[38],
including
in
patients
with
AF[34,39]
Baseline
questionnaires
were
posted
at
least
two
weeks
prior
to
the
ablation
procedure
and
participants
were
reminded
by
the
ward
team
on
admission
to
fill
them
in
before
any
visit
by
doctor
or
study
nurse.
Six-month
ques-
tionnaires
were
posted
to
participants
with
a
follow-up
phone-call
to
ensure
return
to
the
study
co-coordinator.
There
was
100%
compliance
in
filling
out
both
questionnaires
at
both
time
points.
Further
secondary
endpoints
were
re-hospitalisation
for
any
cause
and
re-hospitalisation
for
atrial
fibrillation
at
six
months.
All
patients
were
contacted
by
telephone
at
six
months
to
collect
data
on
re-hospitalisation
and
the
cause
of
hospitalisation
was
adjudicated
by
a
cardiologist
blinded
to
randomisation,
utilising
case
notes,
clinic
letters
and
related
electrocardiograms
and
laboratory
data.
Statistical
Analyses
Data
were
analysed
with
SPSS1
version
19.0
statistical
soft-
ware
package
(SPSS
Inc).
Statistical
comparisons
conformed
to
intention-to-treat
principle.
For
comparisons
between
ran-
domised
groups,
continuous
data
were
analysed
with
the
General
Linear
Model
whereas
categorical
data
were
ana-
lysed
with
the
Chi-square
statistic.
The
pre-
and
post-procedural
education
data
were
ana-
lysed
with
the
General
Linear
Model.
A
preliminary
data
inspection
of
the
AF
Symptom
Checklist,
Frequency
and
Severity
Scale
and
SF-36
data
indicated
some
possible
between-group
differences
in
means
at
baseline
(e.g.
Role-
Physical,
Social
functioning)
therefore
necessitating
statisti-
cal
adjustment.
The
six-month
follow-up
data
of
AF
symp-
tom
severity,
AF
symptom
frequency
and
SF-36
QOL
indices
were
compared
with
analysis
of
covariance
(ANCOVA),
using
the
respective
baseline
scores
as
covariates.
In
this
manner,
the
ANCOVA
procedure
adjusts
for
any
differences
between
study
groups
before
the
ablation
procedure
as
base-
line
scores
are
unrelated
to
the
intervention.
The
secondary
hospitalisation
endpoint
was
analysed
using
the
Chi-statistic.
The
a
priori
sample
size
calculation
[40]
predicted
a
sample
size
of
20
patients
would
be
required
in
each
group
to
yield
sufficient
power
(0.80)
to
test
for
a
significant
difference
(a
=
0.05)
and
large
difference
in
the
primary
endpoint
of
AF
Symptom
Checklist,
Frequency
and
Severity
scores
between
the
two
time-points
(Cohen’s
d
=
.80).
Results
Forty-one
patients
were
included
in
the
study
and
were
randomised
to
NI
or
Control
with
22
and
19
subjects
respec-
tively
(Figure
1).
There
were
no
intention-to-treat
crossover
effects
with
all
participants
receiving
intervention
as
allo-
cated,
and
no
patient
withdrew
from
the
study.
Patients
were
62.1
10.6
years
old;
65.9%
were
male.
The
majority
of
patients
had
paroxysmal
AF
compared
to
non-paroxysmal
69%
vs.
31%.
There
were
no
significant
differences
between
the
Con-
trol
and
Nurse
Intervention
groups
with
respect
to
age,
sex
or
AF
type
(Table
1).
Table
1
Baseline
demographic,
clinical
and
AF
characteristics
CONTROL
N=19
Number/%
NURSE
INTERVENTION
N=22
Number/%
P
value
Age
63.9
10.2
58.3
10.9
0.62
Male
11
57.9
16
76.2
0.32
AF
type
Paroxysmal
14
73.7
15
68.2
0.70
Non-paroxysmal
5
26.3
7
31.8
Mean
BMI
(SD)
(kg/m
2
)
27
(3)
28
(3)
0.89
Sleep
apnoea
6
43.9
5
22.7
0.16
Hypertension
5
26.3
7
31.8
0.43
Heart
failure
1
5.3
2
9.1
0.77
Highest
educational
attainment
Prior
to
secondary
school
completion
12
63.2
11
50.0
0.4Secondary
school
completion
5
26.3
9
40.9
College
2
10.5
2
9.1
76
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All
patients
had
Holter
monitors
at
three
and
six
months
and
as
directed
by
symptoms.
Atrial
fibrillation
recurrence
was
reported
by
seven
patients
in
the
NI
group
and
six
in
the
Control
group.
Atrial
fibrillation
was
documented
by
ECG
or
Holter
in
6/7
and
4/6
patients
respectively.
Primary
Endpoint
There
were
no
significant
differences
in
baseline
variables
in
AF
Symptom
Checklist,
Frequency
and
Severity
scores
between
the
two
groups
with
respect
to
symptom
frequency
or
severity
(Tables
2
and
3).
Overall,
AF
ablation
was
associ-
ated
with
improvements
in
symptom
frequency
and
severity
in
many
of
the
domains
of
the
Checklist
regardless
of
treat-
ment
arm
(Tables
2
and
3).
However,
between-group
analysis
showed
a
significant
difference
in
favour
of
the
nurse-led
intervention
with
respect
to
lower
symptom
frequency
at
six
months
post-ablation
of
the
following
symptoms:
tiredness,
palpitation,
lightheadedness/dizziness,
headache,
trouble
concentrating,
difficulty
sleeping
(Table
2).
There
was
a
trend
to
lower
scores
in
the
NI
groups
compared
with
the
Control
arm
with
respect
to
all
other
symptoms’
frequency.
However,
in
terms
of
severity
of
symptoms,
there
was
no
difference
between
NI
vs.
Control
groups
except
for
difficulty
with
sleeping
(Table
3).
Table
2
AF
Symptom
Checklist,
Frequency
and
Severity
Scale:
Comparisons
of
AF
symptom
frequency
scores
Control
(n=19)
Nurse
Intervention
(n=22)
AF
Symptom
Frequency
Mean
SD
Mean
SD
P
value
(6
months
between
group
analysis)
Tiredness
Baseline
2.58
1.02
2.67
0.97
6
months
1.84
.898
1.43
.507
0.05
Heart
flutter
Baseline
2.32
.95
2.33
1.32
6
months
1.32
.20
.81
.19
0.08
Heart
racing
Baseline
1.79
.98
2.05
1.12
6
months
1.28
.17
.42
.16
<0.001
Lightheadedness/dizziness
Baseline
1.58
1.35
1.71
.96
6
months
1.47
.17
.72
.39
0.003
Headache
Baseline
1.11
1.1
1.1
1.0
6
months
1.05
.21
.48
.20
0.05
Trouble
concentrating
Baseline
1.68
1.00
1.62
.92
6
months
1.20
.18
.58
.17
0.02
Hard
to
catch
breath
Baseline
1.11
1.1
1.48
1.67
6
months
.75
.16
.37
.16
0.11
Shortness
of
breath
Baseline
1.42
1.07
1.67
1.11
6
months
1.17
.19
.71
.18
0.09
Feeling
warm/flushed
Baseline
1.32
1.16
1.29
1.10
6
months
.94
.19
.62
.18
0.25
Sweating
Baseline
1.32
1.25
1.19
1.21
6
months
1.24
.22
.83
.21
0.19
Weakness
Baseline
1.37
1.38
1.71
1.06
6
months
1.08
.17
.64
.16
0.07
Poor
appetite
Baseline
.79
1.03
.86
.91
6
months
.49
.13
.32
.13
0.36
Nausea
Baseline
.89
1.24
.62
.74
6
months
.51
.14
.35
.13
0.38
Difficulty
sleeping
Baseline
1.84
1.34
2.33
.91
6
months
1.95
.22
1.09
.21
0.009
Chest
pain
-
heart
racing
Baseline
1.37
1.21
1.52
1.33
6
months
.66
.20
.49
.19
0.54
Chest
pain
-
heart
not
racing
Baseline
.79
1.08
.57
.81
6
months
.38
.13
.32
.13
0.78
Nurse-led
educational
intervention
in
AF
ablation
77
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Secondary
Endpoints
Again,
AF
ablation
was
associated
with
generally
higher
scores
in
many
SF-36
QOL
domains,
independent
of
treatment
arm
(Table
4).
The
comparative
data
showed
statistically
significant
improvement
in
the
domains
of
physical
functioning
and
vitality
in
the
nurse
interven-
tion
arm,
with
a
positive
trend
in
most
other
domains
(Table
4).
There
was
no
difference
in
total
and
AF-related
hospital
readmissions
at
six
months
between
NI
and
Control
groups
(18.2%
vs.
21.1%
and
13.6%
vs.
10.5%
respectively,
p=NS).
Discussion
This
study
demonstrates
that
patients
who
received
nurse-led,
directed,
educational
intervention
at
the
time
of
AF
ablation
reported
a
significant
decrease
in
frequency
of
many
AF
symptoms
including
tiredness,
palpitations,
lightheadedness/dizziness,
headache,
trouble
concentrat-
ing
and
difficulty
sleeping
compared
to
participants
receiving
ablation
alone.
This
was
despite
similar
rates
of
self-reported
or
documented
arrhythmia
recur-
rence.
The
combination
of
ablation
and
NI
was
also
associated
with
improvement
in
quality
of
life
with
Table
3
AF
Symptom
Checklist
Frequency
and
Severity
Scale:
Comparisons
of
AF
symptom
severity
scores
Control
(n=9)
Nurse
Intervention
(n=21)
AF
Symptom
Severity
Mean
SD
Mean
SD
P
value
(6
months
between
group
analysis)
Tiredness
severity
Baseline
1.58
.61
1.81
.75
6
months
1.27
.14
1.33
.14
0.75
Heart
flutter
Baseline
1.63
.68
1.57
.98
6
months
.94
.19
.87
.18
0.80
Heart
racing
Baseline
1.42
.84
1.57
.87
6
months
.93
.19
.59
.18
0.20
Lightheadedness/dizziness
Baseline
1.05
.97
1.38
.81
6
months
1.02
.16
.65
.34
0.09
Headache
Baseline
.95
1.03
.81
.75
6
months
.82
.15
.45
.14
0.08
Trouble
concentrating
Baseline
1.26
.65
1.10
.63
6
months
.87
.15
.50
.15
0.08
Hard
to
catch
breath
Baseline
.84
.83
1.05
.81
6
months
.57
.12
.34
.11
0.17
Shortness
of
breath
Baseline
1.16
.90
1.33
.97
6
months
.83
.18
.68
.17
0.57
Feeling
warm/flushed
Baseline
.89
.74
1.14
1.01
6
months
.83
.16
.44
.15
0.09
Sweating
Baseline
1.32
1.25
1.19
1.21
6
months
.94
.18
.67
.17
0.29
Weakness
Baseline
.84
.90
1.33
.86
6
months
.82
.16
.64
.15
0.43
Poor
appetite
Baseline
.53
.61
.67
.66
6
months
.46
.11
.25
.11
0.20
Nausea
Baseline
.63
.83
.67
.80
6
months
.48
.13
.28
.12
0.26
Difficulty
sleeping
Baseline
1.37
.96
1.67
.73
6
months
1.29
.17
.79
.16
0.04
Chest
pain
-
heart
racing
Baseline
1.16
1.12
1.24
1.04
6
months
.54
.17
.42
.16
0.60
Chest
pain
-
heart
not
racing
Baseline
.52
.70
.52
.75
6
months
.32
.12
.29
.11
0.86
78
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respect
to
improved
physical
functioning
and
vitality
at
six
months.
The
reasons
for
reduced
symptoms
and
improved
quality
of
life
in
the
nurse
intervention
arm
are
likely
to
be
multifac-
torial,
but
patient
education
is
the
cornerstone.
Structured
patient
education
addressing
patient
concerns
and
recovery
expectations
translated
into
lower
symptom
frequency.
However,
it
is
interesting
that
this
study
demonstrated
improvements
in
symptom
frequency
rather
than
severity.
This
appears
counterintuitive,
but
perhaps
relates
to
a
possi-
ble
effect
of
nurse
education
on
the
interpretation
of
symp-
toms.
It
is
also
possible
that
nurse
intervention
reduces
anxiety
resulting
in
a
positive
impact
on
the
development
and
interpretation
of
AF
symptoms.
Indeed,
this
has
been
shown
in
the
outpatient
setting
in
patients
with
AF[29].
Nurse-led
intervention
has
proven
successful
in
many
areas
of
cardiology[22–25],
including
AF
management
[28,29],
often
as
an
ongoing
component
of
a
multi-disciplin-
ary
approach[30].
However,
in
this
pilot
study,
nurse
inter-
vention
was
relatively
limited,
consisting
of
two
30-minute
face-to-face
meetings
pre-
and
post-ablation
followed
by
three
telephone
calls
over
three
months,
yet
still
produced
positive
effects
on
AF
symptoms
and
quality
of
life.
Perhaps
anchoring
education
to
a
stressful
event
such
as
an
AF
abla-
tion
may
help
explain
the
benefit
seen
in
this
study.
Indeed,
single
time-point
intervention
at
the
time
of
surgery
for
implantable
defibrillators
or
in
the
setting
of
paediatric
surgery
has
been
shown
to
reduce
psychological
morbidity
post-procedure[41,42].
Nurse
intervention
in
this
study
also
included
three
telephone
calls
over
a
three-month
period.
Telephone
support
has
been
well
validated
in
reducing
anx-
iety
and
improving
quality
of
life
in
other
settings
such
as
heart
failure
and
post
coronary
bypass
surgery[43,44]
and
it
is
likely
to
have
an
additive
effect
to
the
face-to-face
educa-
tional
meetings
in
this
trial.
According
to
current
guidelines,
the
principal
purpose
of
catheter
ablation
of
AF
is
to
reduce
patient
symptoms
of
AF
[17,18].
From
the
patient
perspective,
AF
may
be
associated
with
a
variety
of
psychological
symptoms,
including
worry
and
fear[14].
A
paradox
of
AF,
however,
is
that
the
actual
burden
of
AF-related
symptoms
frequently
has
a
limited
relationship
to
the
actual
presence
of
AF[45,46].
To
date,
clinical
AF
guidelines
are
silent
on
this
duality,
which
is
at
the
core
of
AF
treatment[17,18].
The
current
study
aimed
to
evaluate
the
impact
of
a
holistic
nurse-led
educational
intervention
on
AF
symptom
profile
and
quality
of
life.
To
date,
few
data
exist
on
the
impact
of
such
interventions
in
the
AF
ablation
setting.
The
principal
study
finding
was
that
AF
symptom
profile
could
be
improved
by
educational
intervention,
independent
of
AF
ablation
outcome,
is
consistent
with
the
notion
AF-related
symptoms
may
have
psychosocial
as
well
arrhythmia-related
component.
The
results
suggest
the
potential
need
for
explo-
ration
of
alternative
paradigms
of
AF
treatment
involving
addressing
patient
concerns
and
understanding,
as
well
as
reduction
in
actual
AF
burden.
Table
4
SF
36:
Comparison
of
six-month
quality
of
life
functioning
Control
(n=19)
Nurse
Intervention
(n=22)
SF-36
Domain
Mean
SD
Mean
SD
P
value
(6
months
between
group
analysis)
General
health
Baseline
60.68
15.2
62.71
15.71
6
months
64.73
11.92
66.34
13.41
0.63
Physical
functioning
Baseline
62.11
28.88
56.67
27.72
6
months
70.78
23.87
88.58
10.07
0.002
Vitality
Baseline
42.63
20.71
40.24
22.16
6
months
54.31
18.33
70.86
17.05
0.005
Role
-
Physical
Baseline
47.37
45.56
29.76
43.03
6
months
73.42
34.35
68.10
38.99
0.66
Role
-
Emotional
Baseline
71.93
43.41
66.67
40.82
6
months
83.46
32.14
81.63
32.61
0.85
Social
functioning
Baseline
73.68
20.79
58.92
20.97
6
months
80.94
19.24
81.53
22.56
0.93
Bodily
pain
Baseline
62.11
20.70
70.06
19.61
6
months
68.85
26.20
66.04
15.26
0.68
Mental
health
Baseline
74.11
17.15
74.29
15.57
6
months
76.05
16.71
79.57
14.86
0.41
Nurse-led
educational
intervention
in
AF
ablation
79
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Study
Limitations
One
cannot
discount
the
confounding
effect
of
additional
attention
on
the
improved
outcomes
on
frequency
of
many
AF
symptoms
and
improved
quality
of
life
seen
in
the
nurse
intervention
group.
Attention
alone
has
been
shown
to
improve
anxiety[47]
and
other
outcomes
in
clinical
trials
[48]
and
the
use
of
an
attention
control
group
should
be
considered
for
future
studies.
There
was
a
non-significant
difference
in
some
baseline
parameters
between
the
study
groups
including
age,
sex,
educational
level
and
incidence
of
sleep
apnoea
(Table
1).
Some
of
these
differences
may
be
important
in
the
extent
of
symptoms
and
their
interpretation.
While
this
is
inevitable
in
a
randomised
study
of
this
size,
prospective
matching
of
these
variables
should
be
considered
in
future
studies.
With
regards
to
readmission
rates,
although
there
was
no
difference
between
the
two
groups,
the
number
of
patients
recruited
in
the
study
was
small
and
was
under-powered
with
respect
to
that
outcome.
Larger
trials
with
longer
follow-
up
would
be
required
to
determine
the
efficacy
of
NI
on
readmissions
post-ablation.
The
study
findings
are
presented
with
other
limitations
including
recruitment
from
a
single
hospital
site
and
referral
bias
for
ablation
which
may
temper
the
generalisability
to
other
settings.
A
strength
of
the
study
was
the
use
of
a
single
nurse
for
the
NI
arm
which
allows
more
homogeneity
in
delivery
of
the
education
intervention
and
follow-up.
Conclusion
In
conclusion,
this
study
demonstrates
that
focussed
nurse-
led
education
at
the
time
of
AF
ablation
is
associated
with
improved
symptoms
and
quality
of
life,
the
effect
of
which
persists
beyond
the
last
contact
with
the
patients,
and
is
independent
of
ablation
outcome.
Nurse-led
intervention
at
the
time
of
catheter
ablation
is
simple,
effective
and
easily
translatable
to
clinical
practice
and
should
be
considered
as
part
of
a
multi-disciplinary
approach
to
patients
undergoing
AF
ablation.
Further
work
is
required
to
best
characterise
the
optimal
timing
and
frequency
of
this
strategy.
Disclosures
Prof
McGavigan
has
received
grant
support,
speaker
fees,
honoraria
and
travel
support
from
Bayer,
Boston
Scientific,
Biotronik,
Medtronic,
Pfizer
and
St
Jude
Medical.
Dr
Ganesan
is
supported
by
an
Australian
Early
Career
Health
Practitioner
Fellowship
from
the
National
Health
and
Medical
Research
Council
of
Australia.
There
are
no
relevant
disclosures
from
other
authors.
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