Does Cardioversion for AF Improve Quality of Life?

It seems at first glance to be self-evident that sinus rhythm is preferable to atrial fibrillation (AF). However, even with decades of observational studies, clinical trials, and innumerable caregiver-patient interactions, it continues to be deceptively difficult to verify this common sense expectation, says an Editorial article to appear in Canadian Journal of Cardiology.

See Also: Over 50% of AF Patients Become Asymptomatic After Ablation

Few clinicians would doubt that in many patients with AF, particularly those who are very symptomatic, the restoration and maintenance of sinus rhythm is desirable and results in improved subjective well-being and improved life satisfaction. But the article says a more pertinent question may be: “In which patients will treatment meaningfully improve overall quality of life, taking into account the risks and adverse symptoms which may be associated with treatment?”

Larger perceived benefits of sinus rhythm restoration would logically lead to a greater desire on the part of patients and caregivers to attempt this strategy, even if the probability of it being successful was lower, according to article authors Paul Dorian, MD, MSc, Department of Medicine, University of Toronto and Division of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada, and Andrew C. T. Ha, MD, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto.

The article cites Sandhu et al.'s prospective study which "helps us understand the magnitude of quality of life change after cardioversion in patients with persistent atrial fibrillation." The study also helps confirm what most clinicians believe, that patients referred for elective cardioversion for AF (where presumably caregivers and patients have jointly decided that an attempt to restore sinus rhythm is clinically worthwhile) can derive substantial benefit from cardioversion provided that sinus rhythm is maintained at 3 months. The study, however, does not inform us about the long-term outcomes after cardioversion, which are relevant in this chronic illness, Drs. Dorian and Ha note in the article.

Previous studies have shown that there is a very wide variation of change in quality of life with treatment, including following restoration of sinus rhythm. In some patients, quality of life improves minimally, whereas in others there is a great deal of improvement; patients with poorer quality of life at baseline tend to show the greatest degree of improvement with therapy.

"Although studies such as Sandhu et al. help confirm that in most patients referred for cardioversion, an attempt to restore and maintain sinus rhythm is worthwhile from a patient perspective, it remains difficult to parse out which components of subjective improvement contribute to the increased well-being, and to what degree, in individual patients," the article says. "Some of the improvement is certain to be directly related to the treatment effect itself, i.e., the absence of symptoms related to atrial fibrillation. Some of the improvement is likely related to 'treatment expectancy' whereby patients expect to get improvement from a medical intervention and this improvement becomes a 'self-fulfilling prophecy' even if the intervention itself is ineffective."  

Drs. Dorian and Ha also note the need for more studies such as the ones by Sandhu et al, in larger cohorts followed for longer periods of time, to determine which patients can derive the greatest subjective improvement from the restoration of sinus rhythm, and to help balance the benefits versus the risks of therapies intended to maintain sinus rhythm such as anti-arrhythmic drugs or catheter-based ablation.

Source: Canadian Journal of Cardiology
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