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International Journal of Nursing Practice 2015; 21: 749–755
RESEARCH PAPER
Profile of atrial fibrillation inpatients: Cardiovascular risk factors and cardiac rehabilitation programme delivery and referral patterns Robyn Gallagher RN PhD Associate Professor, Chronic and Complex Care, Faculty of Health, University of Technology, Sydney, Sydney, New South Wales, Australia
Ling Zhang RN BN (Hons) Registered Nurse, Faculty of Health, University of Technology, Sydney, Sydney, New South Wales, Australia
Kellie Roach RN Nurse Coordinator and Clinical Nurse Consultant, Cardiac Rehabilitation, Ryde Hospital, Sydney, New South Wales, Australia
Leonie Sadler RN Clinical Nurse Consultant, Cardiac Rehabilitation, Manly Hospital, Sydney, New South Wales, Australia
Julie Belshaw RN Clinical Nurse Consultant, Cardiac Rehabilitation, Hornsby Ku-ring-gai Health Services, Sydney, New South Wales, Australia
Ann Kirkness RN Clinical Nurse Consultant, North Shore Cardiovascular Education Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
Ross Proctor RN Clinical Nurse Consultant, Royal North Shore Hospital, Sydney, New South Wales, Australia
Lis Neubeck PhD RN Senior Research Fellow, Cardiovascular, and Adjunct Senior Lecturer, Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
Accepted for publication March 2014 Gallagher R, Zhang L, Roach K, Sadler L, Belshaw J, Kirkness A, Proctor R, Neubeck L. International Journal of Nursing Practice 2015; 21: 749–755 Profile of atrial fibrillation inpatients: Cardiovascular risk factors and cardiac rehabilitation programme delivery and referral patterns
Correspondence: Robyn Gallagher, Faculty of Health, University of Technology, 15 Broadway, Sydney, NSW 2007, Australia. Email: [email protected] doi:10.1111/ijn.12337
© 2014 Wiley Publishing Asia Pty Ltd
R Gallagher et al.
750
Atrial fibrillation (AF) is increasingly common; however, the cardiovascular risk factor profile and the patterns of delivery and referral to cardiac rehabilitation (CR) in this population are poorly described. We conducted an audit of medical records (n = 145) of patients admitted with AF in one local health district in Sydney, Australia. Patients were aged a mean 72 years, and 51% were male. Lack of risk factor documentation was common. Despite this, 65% had two or more modifiable cardiovascular risk factors, including hypertension (63%) and hypercholesterolaemia (52%). Referral to Phase II CR occurred for 25% and was decreased with permanent AF diagnosis and increased with more risk factors. AF patients admitted to hospital have multiple cardiovascular risk factors but limited risk factor screening and/or referral to outpatient CR programmes. Key words: atrial fibrillation, cardiac rehabilitation, cardiovascular risk factors.
INTRODUCTION
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It affects 1–2% of the population, but rates are projected to double in the next 50 years, primarily due to the ageing population.1–3 In Australia, it was estimated by the National Stroke Foundation that there were 240 000 people, or 1.1% of the population, suffering from AF during 2008–2009.4 AF is a serious condition because it significantly increases the risk of developing heart failure, thromboembolism, stroke and death if the condition is left untreated or unmanaged.5 In people who have AF the risk of stroke is 2.5 to 7 times greater,6 the risk of mortality is approximately doubled, and over 10% of people with AF die in the first year of their diagnosis.2,6 AF causes more than 45 000 hospitalisations a year and costs the Australian health system more than A$874 million annually.7 AF also has a substantial impact on patients’ lives through symptoms, which include dizziness, dyspnoea, chest pain and reduced exercise capacity and leads to decreases in exercise participation, functional capacity and health-related quality of life (HRQoL).8–10 Patients also report emotional distress related to the unpredictability of AF paroxysms and the physical limitations that AF causes.11,12 These effects can be even more pronounced in older people8,13 and require appropriate self-management. Self-management of AF includes reduction of the modifiable factors known to contribute to the risk of AF. Aside from the minor proportion of AF diagnoses due to excessive exercise and caffeine intake, the majority of modifiable risk factors are common to all cardiovascular diseases. These factors include hypertension, hypercholesterolaemia, diabetes, smoking, obesity and sedentary behaviour.14–19 Screening and interventions to support © 2014 Wiley Publishing Asia Pty Ltd
modification of these risk factors are warranted for this population. Despite the need for programmes to support selfmanagement of these multiple issues, few interventions have been tested in this population, and most have a single focus. For instance, a systematic review of exercise training demonstrated improvements in exercise capacity and HRQoL.20 One primary care programme that had a focus on weight loss was also shown to reduce AF burden.21 However, when patient education and psychosocial support for the chronic condition are included in a programme, reduction in cardiovascular-related hospitalisations and deaths can also be achieved.22 Cardiac rehabilitation (CR) programmes provide strong potential to support AF patients’ needs through inpatient behavioural counselling and education (Phase I interventions) and outpatient exercise, behavioural counselling and education programmes (Phase II interventions).23 CR has been demonstrated to improve exercise capacity, risk factor reduction, adjustment to illness and self-management in cardiovascular patients.24 Importantly, CR has well-established systems for screening inpatients and referral to programmes. CR is recommended by peak bodies for patients recovering from coronary heart disease events and cardiac surgery, but the role of CR for AF patients is less clear.4,6,25 This is due in part to the lack of information on the profile of AF inpatients, making it unclear what CR inpatient or outpatient services might be required. Lack of information on current patterns of delivery and referral of Phase I and II CR or other cardiac programmes contributes to this uncertainty. Therefore, our aim was to describe the profile of AF inpatients including modifiable cardiovascular risk factors and CR programme delivery and referral.
Atrial fibrillation inpatient profile
METHODS Design
751
Procedure
A prospective audit of medical records for patients admitted with an AF diagnosis in the Northern Sydney Local Health District, Sydney, Australia.
CR staff screened wards for eligible charts from July 2012 to April 2013. Of the 204 charts screened, 142 were found to be eligible using the criteria above and are included in the study.
Setting and sample
Data analysis
Northern Sydney Local Health District includes five hospitals that have CR programmes; one is a tertiary referral hospital and four are community hospitals. The medical records considered eligible for the study were for patients admitted with AF to cardiac wards routinely screened by CR staff. Charts were excluded if there was documentation of moderate or severe dementia, chronic congestive cardiac failure, an end-stage chronic disease such as chronic obstructive pulmonary disease, non-cardiacrelated surgical treatment or booking for transfer to a convalescent or general rehabilitation service, as these criteria are common exclusions for CR programmes in the study setting. All hospitals and the university provided human research ethics committee approval for this lowrisk study, which conforms to the requirements stated in the Declaration of Helsinki.26 Sample size was calculated for the logistic regression analyses to be 127 on the basis of including 12 variables in the analyses, power of 0.8, alpha of 0.05 and effect size of 0.15. An allowance of 14% for drop-out from first screening to hospital discharge meant that 147 charts were included.
Data collection An audit tool was developed specifically for the study, as a review of the literature did not identify a suitable tool. The tool was used to extract data from the medical record for sociodemographics, clinical history, current admission diagnosis details, history of AF and cardiovascular disease risk factors (family history, hypertension, hypercholesterolaemia, sedentary lifestyle, overweight, diabetes, smoking history and depression). Data were also extracted related to any delivery or referral to Phase I and II CR or other cardiac programmes available in the health district. The tool was then tested on a sample of 15 medical records of patients who had AF and modifications made to the format of the tool. All CR staff participating in data collection were experts in CR and attended a 2 h training workshop in data collection and audit methods to ensure standardised approaches.
Data were entered into and analysed using SPSS v. 22. Means and standard deviations, frequencies and percentages were used to describe data. Many patients did not have evidence of screening or documentation for risk factors. For the purposes of the analyses these patients were classified as not having the risk factor. Comparisons of variables for whether patients received Phase I CR or were referred to Phase II CR were conducted using chisquared test for categorical data and Student’s t-test for continuous data. Logistic regression analysis was used to determine the independent predictors of referral to Phase II CR. Variables in the analysis included age, gender, AF classification, hypertension, hypercholesterolaemia, sedentary habits, overweight, diabetes, number of modifiable risk factors and ischaemic heart disease. The backwards logistic regression technique was used to create the most parsimonious model, and the critical level was set at < 0.05.
RESULTS The sample had a mean age of 72 years (SD 12.25, range 30–89 years), and approximately half (51%) of the sample were male (Table 1). The most common type of AF on admission was paroxysmal (52%), followed by permanent (28%), and for the majority of patients (81%), AF was one of multiple diagnoses. The most common comorbid disease was ischaemic heart disease (27%), followed by respiratory disease (20%).
Cardiovascular risk factors Despite patients being admitted to cardiac wards, failure to screen and/or document cardiovascular risk factors was common. The modifiable cardiovascular risk factors that were most often not documented included depression and sedentary habits (both 48%) and overweight/ obesity (32%) (Table 2). Despite the lack of documentation, risk factors were very common, with patients having an average 2.22 (SD 1.61) risk factors. Only 16% had no risk factor, and 65% had two or more. The most © 2014 Wiley Publishing Asia Pty Ltd
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Table 2 Cardiovascular risk factor prevalence and documentation
Table 1 Sample characteristics Characteristic (n = 142)
Overall
Age, mean (SD) Male gender, n (%) AF classification this admission Paroxysmal (< 48 h) Permanent Persistent (days/weeks) Atrial flutter AF one of multiple diagnoses on admission History of AF Chronic and comorbid conditions, n (%)† Cardiac Ischaemic heart disease Myocardial infarction PCI CABG Valve disease/surgery Heart failure Pacemaker ICD Noncardiac Respiratory disease CVA/TIA Alcohol abuse Sleep apnea Peripheral vascular disease Other (hyperthyroidism, CRF, etc.)
72.01 (12.25) 72 (51) 74 (52) 39 (28) 24 (17) 5 (4) 166 (81) 88 (62)
38 (27) 18 (13) 18 (13) 11 (8) 20 (14) 24 (17) 10 (7) 5 (4) 28 (20) 16 (11) 9 (6) 7 (5) 7 (5) 11 (8)
Characteristic (n = 142)
Overall, n (%)
Not documented, n (%)
Hypertension Hypercholesterolaemia Sedentary Overweight Diabetes Smoking (current/recent) Family history CVD Depression
89 (63) 74 (52) 37 (26) 37 (26) 26 (18) 23 (16) 17 (12) 9 (6)
12 (9) 28 (20) 68 (48) 45 (32) 28 (20) 22 (16) 48 (34) 68 (48)
CVD, cardiovascular disease. Table 3 Cardiovascular risk factor reduction programme delivery and referral Programme
n (%)†
Cardiac rehabilitation Phase I Phase II Phases I and II Heart failure programme
100 (70) 35 (25) 26 (18) 18 (13)
†
Percentages do not total 100, as multiple options are possible and some values are missing.
†
Multiple diagnoses possible. AF, atrial fibrillation; CABG, coronary artery bypass graft; CRF, chronic renal failure; CVA, cerebral vascular accident; ICD, implantable cardioverter– defibrillator; PCI, percutaneous coronary intervention; TIA, transient ischaemic event.
common modifiable risk factors were hypertension (63%) and hypercholesterolaemia (52%).
Cardiovascular risk factor reduction programme delivery and referral The majority (70%) of the sample received Phase I CR; one in four patients (25%) was referred to a Phase II CR programme, and a small proportion (13%) were referred to the heart failure programme (Table 3). Fifteen per cent did not receive or were not referred to any CR or heart failure programme. Similar reasons were provided by CR staff for not delivering Phase I CR and not referring to © 2014 Wiley Publishing Asia Pty Ltd
Phase II CR, and these were that admission time was short so that they missed the patient (24% and 19%) or that the patient was being transferred or had other treatment planned (19% and 7%). Patients who were referred for Phase II CR had more risk factors than those who were not referred (2.83 vs. 2.01, P = 0.008) and were more likely to have hypercholesterolaemia (67% vs. 47%, P = 0.03), to be overweight or obese (42% vs. 21%, P = 0.014) and not to get enough exercise (39% vs. 22%, P = 0.037) (Table 4). There were differences in referral to Phase II CR for age, gender, type of AF, presence of ischaemic heart disease and other CVD risk factors. We determined the independent predictors of referral to Phase II CR using backwards logistic regression for the most parsimonious model (χ2= 20.1, P = 0.001), and there were two significant predictors. The odds of referral were decreased by having permanent AF versus other types (OR = 0.09, 95% CI
753
Atrial fibrillation inpatient profile
Table 4 Comparison of patients with AF by referral to Phase II cardiac rehabilitation Characteristic
Referred (n = 36)
Not referred (n = 106)
P value†
Total risk factors, mean (SD) Age (years), mean (SD) Male gender, n (%) History of IHD, n (%) Family history of CVD, n (%) Diabetes, n (%) Hypercholesterolaemia, n (%) Hypertension, n (%) Smoker, n (%) Overweight/obese, n (%) Low exercise, n (%) Depression, n (%) AF classification, n (%) Paroxysmal AF Permanent AF Persistent AF
2.83 (1.63) 70.8 (10.19) 19 (53) 7 (19) 6 (17) 6 (17) 24 (67) 24 (67) 8 (22) 15 (42) 14 (39) 3 (8)
2.01 (1.56) 72.16 (12.5) 54 (51) 31 (29) 11 (10) 20 (19) 50 (47) 65 (61) 15 (14) 22 (21) 23 (22) 6 (6)
0.008 0.680 0.620 0.170 0.230 0.490 0.030 0.360 0.19 0.014 0.037 0.410 0.080
23 (64) 4 (11) 17 (47)
51 (48) 35 (33) 17 (16)
†
t-Test for continuous variables, chi-squared test for categorical variables. AF, atrial fibrillation; CVD, cardiovascular disease; IHD, ischaemic heart disease; SD, standard deviation.
0.01–0.78; P = 0.029) and increased with more risk factors (OR = 1.75, 95% CI 1.25–2.45; P = 0.001).
DISCUSSION Our results indicate that the majority of patients admitted to hospital with AF are older and have multiple comorbid conditions as well as many modifiable cardiovascular risk factors such as hypertension and hypercholesterolaemia. The majority of patients had paroxysmal AF, and one in four had permanent AF, so that symptoms and treatments would need to be managed in an ongoing way, further emphasising the need for support. Although the literature indicates a high prevalence of cardiovascular risk factors in people with AF, we observed that many patients were not screened for these factors. Furthermore, although the majority of AF patients received Phase I CR, the majority were not referred to Phase II programmes. Patients with more risk factors and those who did not have permanent AF were more likely to be referred to Phase II CR. Our study contributes to the mounting body of evidence that AF patients are likely to have high selfmanagement requirements because their AF is chronic and they often suffer from multiple pre-existing and contributing cardiac conditions, other comorbid diseases27,28
and age-related changes.8 AF should be considered a chronic condition, as the majority of patients hospitalised with AF had experienced AF previously, and more than one in four had permanent AF. Despite this, the main focus in the literature and international guidelines is on achieving sinus rhythm and not so much on adjusting to AF as a chronic condition.16,25 However, this focus could be misdirected, as a recent review concluded that achieving sinus rhythm in AF patients does not confer substantial benefits in terms of morbidity and mortality.16 Instead, a lifelong approach that includes prevention of thromboembolic events and attention to other comorbid conditions is likely needed. Thromboembolic event prevention is of paramount importance, as even very short episodes of AF confer high risk of thromboembolic complications.29 Other comorbid conditions can reduce HRQoL, particularly in older people who have AF.8,13,15 Despite this, AF patients report that they do not receive counselling regarding the nature of AF, AF treatment, psychosocial adjustment or self-management,11 and, as our study shows, patients with permanent AF were less likely to be referred to Phase II CR, in spite of the demonstrated benefits for supporting functional capacity and self-care.6,24,25 © 2014 Wiley Publishing Asia Pty Ltd
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Given that CR is also an appropriate and effective intervention for reducing the modifiable cardiovascular risk factors prevalent in this population, it would be expected that Phase I and Phase II CR would be routine. However, CR is not systematically considered or delivered to AF patients, nor do referrals occur in a standardised way, as our study and others show.24 A factor that might contribute to lack of referral is that cardiovascular risk factors do not seem to be routinely screened or documented during admission, with depression, sedentary lifestyle and overweight/obesity the factors most often neglected. Lack of screening and documentation has several potentially negative effects including limiting awareness by health professionals and patients, discussion of risk factor management and referral to Phase II CR. Patients with fewer documented risk factors in the current study were less likely to be referred to Phase II CR, and therefore they were missing out on receiving appropriate, effective treatments.30 Given the growing body of evidence for the benefits of structured exercise, such as that included in Phase II CR, for AF patients’ exercise capacity and HRQoL, this is an important deficit.14,20,22 Further research is required that tests the effectiveness of multidisciplinary CR in AF patients.
Limitations Patients who did not have a risk documented were classified as not having the risk factor, which might underestimate the prevalence of that factor, and future research should include systematic screening rather than an audit.
Conclusions and implications for practice AF patients admitted to hospital tend to be older and to have multiple health conditions and cardiovascular risk factors and are in need of assessment and support by health professionals. Systematic screening for cardiovascular risk factors should be standard practice for people with AF. People with AF need advice and support for risk factor reduction to address medication adherence and to improve HRQoL. CR services are ideal settings for implementation of a structured management programme for AF rehabilitation services and provide an untapped resource that could improve risk factors, increase HRQoL and improve medication adherence in this population. © 2014 Wiley Publishing Asia Pty Ltd
ACKNOWLEDGEMENTS We would like to acknowledge Patrick Gallagher for his contribution to data entry and manuscript revision and production. This research received no specific grant from any funding agency in the public, commercial or not-forprofit sectors. LN is supported by an NHMRC early career fellowship (APP1036763).
REFERENCES 1 American College of Cardiology Foundation; American Heart Association. ACCF/AHA Pocket Guideline: Management of patients with atrial fibrillation. 2011. Available from URL: http://my.americanheart.org/idc/groups/ ahamah-public/@wcm/@sop/@spub/documents/ downloadable/ucm_427314.pdf. Accessed 13 February 2013. 2 Suzuki S, Yamashita T, Otsuka T et al. Recent mortality of Japanese patients with atrial fibrillation in an urban city of Tokyo. Journal of Cardiology 2011; 58: 116– 123. 3 Kang Y. The relationships between uncertainty and its antecedents in Korean patients with atrial fibrillation. Journal of Clinical Nursing 2010; 20: 1880–1886. 4 National Stroke Foundation. The economic costs of atrial fibrillation in Australia. 2010. Available from URL: http:// www.strokefoundation.com.au/index2.php?option=com _docman&task=doc_view&gid318&itemid=39. Accessed 13 February 2013. 5 White MM. Treatment strategies for atrial fibrillation. The Nurse Practitioner 2010; 35: 25–29. 6 American Heart Association. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: Executive summary. Circulation 2006; 114: 700–752. 7 Australian Institute of Health and Welfare. Chronic diseases. 2013. Available from URL: http://www.aihw.gov .au/chronic-diseases. Accessed 13 February 2013. 8 Kang Y, Bahler R. Health-related quality of life in patients newly diagnosed with atrial fibrillation. European Journal of Cardiovascular Nursing 2004; 3: 71–76. 9 Singh SN, Tang XC, Singh BN et al. Quality of life and exercise performance in patients in sinus rhythm versus persistent atrial fibrillation: A Veterans Affairs Cooperative Studies Program substudy. Journal of the American College of Cardiology 2006; 48: 721–730. 10 Pinter A, Dorian P. New approaches to atrial fibrillation management: Treat the patient, not the ECG. Cardiovascular Therapeutics 2010; 28: 302–310. 11 McCabe PJ, Schumacher K, Barnason SA. Living with atrial fibrillation: A qualitative study. The Journal of Cardiovascular Nursing 2011; 26: 336–344. 12 Dalteg T, Benzein E, Sandgren A, Fridlund B, Malm D. Managing uncertainty in couples living with atrial
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19 20
21
fibrillation. The Journal of Cardiovascular Nursing 2014; 29: E1–E10. Steg PG, Alam S, Chiang C et al. Symptoms, functional status and quality of life in patients with controlled and uncontrolled atrial fibrillation: Data from the RealiseAF cross-sectional international registry. Heart (British Cardiac Society) 2012; 98: 195–201. Lowres N, Neubeck L, Freedman SB, Briffa T, Bauman A, Redfern J. Lifestyle risk reduction interventions in atrial fibrillation: A systematic review. European Journal of Cardiovascular Prevention and Rehabilitation 2012; 19: 1091– 1100. Cottrell C. Atrial fibrillation part 1: Pathophysiology. Practice Nursing 2012; 23: 16–22. Rosengren A, Hauptman PJ, Lappas G, Olsson L, Wilhelmsen L, Swedberg K. Big men and atrial fibrillation: Effects of body size and weight gain on risk of atrial fibrillation in men. European Heart Journal 2009; 30: 1113–1120. Conen D, Osswald S, Albert CM. Epidemiology of atrial fibrillation. Swiss Medical Weekly 2009; 139: 346–352. Schoonderwoerd BA, Smit MD, Pen L, Van Gelder IC. New risk factors for atrial fibrillation: Causes of ‘not-soalone atrial fibrillation’. Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology 2008; 10: 668–673. Benjamin EJ, Chen P, Bild DE et al. Prevention of atrial fibrillation: Report from a National Heart, Lung, and Blood Institute workshop. Circulation 2009; 119: 606–618. Giacomantonio NB, Bredin SSD, Foulds HJA, Warburton DER. A systematic review of the health benefits of exercise rehabilitation in persons living with atrial fibrillation. The Canadian Journal of Cardiology 2013; 29: 483–491. Sanders AR, van Weeghel I, Vogelaar M et al. Effects of improved patient participation in primary care on healthrelated outcomes: A systematic review. Family Practice 2013; 30: 365–378.
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22 Hendriks JML, Wit RD, Crijns HJGM et al. Nurse-led care versus usual care for patients with atrial fibrillation: Results from a randomized trial of integrated care versus routine clinical care in ambulatory patients with atrial fibrillation. European Heart Journal 2012; 33: 2692–2699. 23 Berti D, Hendriks JM, Brandes A et al. A proposal for interdisciplinary, nurse-coordinated atrial fibrillation expert programmes as a way to structure daily practice. European Heart Journal 2013; 34: 2725–2730. 24 Camm AJ, Lip GY, De Caterina R et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. European Heart Journal 2012; 33: 2719–2747. 25 Bennett BM, Nakamura E. Ethics of human experimentation. British Medical Journal 1964; 2: 135–136. 26 Mertens DJ. Exercise training for patients with chronic atrial fibrillation. Journal of Cardiopulmonary Rehabilitation 2006; 26: 30–31. 27 Ball J, Carrington MJ, McMurry JJV, Stewart S. Atrial fibrillation: Profile and burden of an evolving epidemic in the 21st century. International Journal of Cardiology 2013; 167: 1807–1824. 28 Healey JS, Connolly SJ, Gold MR et al. Subclinical atrial fibrillation and the risk of stroke. The New England Journal of Medicine 2012; 366: 120–129. 29 Shepherd CW, While AE. Cardiac rehabilitation and quality of life: A systematic review. International Journal of Nursing Studies 2012; 49: 755–771. 30 Risom SS, Zwisler AD, Rasmussen TB et al. The effect of integrated cardiac rehabilitation versus treatment as usual for atrial fibrillation patients treated with ablation: The randomised CopenHeartRFA trial protocol. BMJ Open 2013; 3: e02377.
© 2014 Wiley Publishing Asia Pty Ltd
International Journal of Nursing Practice 2015; 21: 749–755
RESEARCH PAPER
Profile of atrial fibrillation inpatients: Cardiovascular risk factors and cardiac rehabilitation programme delivery and referral patterns Robyn Gallagher RN PhD Associate Professor, Chronic and Complex Care, Faculty of Health, University of Technology, Sydney, Sydney, New South Wales, Australia
Ling Zhang RN BN (Hons) Registered Nurse, Faculty of Health, University of Technology, Sydney, Sydney, New South Wales, Australia
Kellie Roach RN Nurse Coordinator and Clinical Nurse Consultant, Cardiac Rehabilitation, Ryde Hospital, Sydney, New South Wales, Australia
Leonie Sadler RN Clinical Nurse Consultant, Cardiac Rehabilitation, Manly Hospital, Sydney, New South Wales, Australia
Julie Belshaw RN Clinical Nurse Consultant, Cardiac Rehabilitation, Hornsby Ku-ring-gai Health Services, Sydney, New South Wales, Australia
Ann Kirkness RN Clinical Nurse Consultant, North Shore Cardiovascular Education Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
Ross Proctor RN Clinical Nurse Consultant, Royal North Shore Hospital, Sydney, New South Wales, Australia
Lis Neubeck PhD RN Senior Research Fellow, Cardiovascular, and Adjunct Senior Lecturer, Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
Accepted for publication March 2014 Gallagher R, Zhang L, Roach K, Sadler L, Belshaw J, Kirkness A, Proctor R, Neubeck L. International Journal of Nursing Practice 2015; 21: 749–755 Profile of atrial fibrillation inpatients: Cardiovascular risk factors and cardiac rehabilitation programme delivery and referral patterns
Correspondence: Robyn Gallagher, Faculty of Health, University of Technology, 15 Broadway, Sydney, NSW 2007, Australia. Email: [email protected] doi:10.1111/ijn.12337
© 2014 Wiley Publishing Asia Pty Ltd
R Gallagher et al.
750
Atrial fibrillation (AF) is increasingly common; however, the cardiovascular risk factor profile and the patterns of delivery and referral to cardiac rehabilitation (CR) in this population are poorly described. We conducted an audit of medical records (n = 145) of patients admitted with AF in one local health district in Sydney, Australia. Patients were aged a mean 72 years, and 51% were male. Lack of risk factor documentation was common. Despite this, 65% had two or more modifiable cardiovascular risk factors, including hypertension (63%) and hypercholesterolaemia (52%). Referral to Phase II CR occurred for 25% and was decreased with permanent AF diagnosis and increased with more risk factors. AF patients admitted to hospital have multiple cardiovascular risk factors but limited risk factor screening and/or referral to outpatient CR programmes. Key words: atrial fibrillation, cardiac rehabilitation, cardiovascular risk factors.
INTRODUCTION
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It affects 1–2% of the population, but rates are projected to double in the next 50 years, primarily due to the ageing population.1–3 In Australia, it was estimated by the National Stroke Foundation that there were 240 000 people, or 1.1% of the population, suffering from AF during 2008–2009.4 AF is a serious condition because it significantly increases the risk of developing heart failure, thromboembolism, stroke and death if the condition is left untreated or unmanaged.5 In people who have AF the risk of stroke is 2.5 to 7 times greater,6 the risk of mortality is approximately doubled, and over 10% of people with AF die in the first year of their diagnosis.2,6 AF causes more than 45 000 hospitalisations a year and costs the Australian health system more than A$874 million annually.7 AF also has a substantial impact on patients’ lives through symptoms, which include dizziness, dyspnoea, chest pain and reduced exercise capacity and leads to decreases in exercise participation, functional capacity and health-related quality of life (HRQoL).8–10 Patients also report emotional distress related to the unpredictability of AF paroxysms and the physical limitations that AF causes.11,12 These effects can be even more pronounced in older people8,13 and require appropriate self-management. Self-management of AF includes reduction of the modifiable factors known to contribute to the risk of AF. Aside from the minor proportion of AF diagnoses due to excessive exercise and caffeine intake, the majority of modifiable risk factors are common to all cardiovascular diseases. These factors include hypertension, hypercholesterolaemia, diabetes, smoking, obesity and sedentary behaviour.14–19 Screening and interventions to support © 2014 Wiley Publishing Asia Pty Ltd
modification of these risk factors are warranted for this population. Despite the need for programmes to support selfmanagement of these multiple issues, few interventions have been tested in this population, and most have a single focus. For instance, a systematic review of exercise training demonstrated improvements in exercise capacity and HRQoL.20 One primary care programme that had a focus on weight loss was also shown to reduce AF burden.21 However, when patient education and psychosocial support for the chronic condition are included in a programme, reduction in cardiovascular-related hospitalisations and deaths can also be achieved.22 Cardiac rehabilitation (CR) programmes provide strong potential to support AF patients’ needs through inpatient behavioural counselling and education (Phase I interventions) and outpatient exercise, behavioural counselling and education programmes (Phase II interventions).23 CR has been demonstrated to improve exercise capacity, risk factor reduction, adjustment to illness and self-management in cardiovascular patients.24 Importantly, CR has well-established systems for screening inpatients and referral to programmes. CR is recommended by peak bodies for patients recovering from coronary heart disease events and cardiac surgery, but the role of CR for AF patients is less clear.4,6,25 This is due in part to the lack of information on the profile of AF inpatients, making it unclear what CR inpatient or outpatient services might be required. Lack of information on current patterns of delivery and referral of Phase I and II CR or other cardiac programmes contributes to this uncertainty. Therefore, our aim was to describe the profile of AF inpatients including modifiable cardiovascular risk factors and CR programme delivery and referral.
Atrial fibrillation inpatient profile
METHODS Design
751
Procedure
A prospective audit of medical records for patients admitted with an AF diagnosis in the Northern Sydney Local Health District, Sydney, Australia.
CR staff screened wards for eligible charts from July 2012 to April 2013. Of the 204 charts screened, 142 were found to be eligible using the criteria above and are included in the study.
Setting and sample
Data analysis
Northern Sydney Local Health District includes five hospitals that have CR programmes; one is a tertiary referral hospital and four are community hospitals. The medical records considered eligible for the study were for patients admitted with AF to cardiac wards routinely screened by CR staff. Charts were excluded if there was documentation of moderate or severe dementia, chronic congestive cardiac failure, an end-stage chronic disease such as chronic obstructive pulmonary disease, non-cardiacrelated surgical treatment or booking for transfer to a convalescent or general rehabilitation service, as these criteria are common exclusions for CR programmes in the study setting. All hospitals and the university provided human research ethics committee approval for this lowrisk study, which conforms to the requirements stated in the Declaration of Helsinki.26 Sample size was calculated for the logistic regression analyses to be 127 on the basis of including 12 variables in the analyses, power of 0.8, alpha of 0.05 and effect size of 0.15. An allowance of 14% for drop-out from first screening to hospital discharge meant that 147 charts were included.
Data collection An audit tool was developed specifically for the study, as a review of the literature did not identify a suitable tool. The tool was used to extract data from the medical record for sociodemographics, clinical history, current admission diagnosis details, history of AF and cardiovascular disease risk factors (family history, hypertension, hypercholesterolaemia, sedentary lifestyle, overweight, diabetes, smoking history and depression). Data were also extracted related to any delivery or referral to Phase I and II CR or other cardiac programmes available in the health district. The tool was then tested on a sample of 15 medical records of patients who had AF and modifications made to the format of the tool. All CR staff participating in data collection were experts in CR and attended a 2 h training workshop in data collection and audit methods to ensure standardised approaches.
Data were entered into and analysed using SPSS v. 22. Means and standard deviations, frequencies and percentages were used to describe data. Many patients did not have evidence of screening or documentation for risk factors. For the purposes of the analyses these patients were classified as not having the risk factor. Comparisons of variables for whether patients received Phase I CR or were referred to Phase II CR were conducted using chisquared test for categorical data and Student’s t-test for continuous data. Logistic regression analysis was used to determine the independent predictors of referral to Phase II CR. Variables in the analysis included age, gender, AF classification, hypertension, hypercholesterolaemia, sedentary habits, overweight, diabetes, number of modifiable risk factors and ischaemic heart disease. The backwards logistic regression technique was used to create the most parsimonious model, and the critical level was set at < 0.05.
RESULTS The sample had a mean age of 72 years (SD 12.25, range 30–89 years), and approximately half (51%) of the sample were male (Table 1). The most common type of AF on admission was paroxysmal (52%), followed by permanent (28%), and for the majority of patients (81%), AF was one of multiple diagnoses. The most common comorbid disease was ischaemic heart disease (27%), followed by respiratory disease (20%).
Cardiovascular risk factors Despite patients being admitted to cardiac wards, failure to screen and/or document cardiovascular risk factors was common. The modifiable cardiovascular risk factors that were most often not documented included depression and sedentary habits (both 48%) and overweight/ obesity (32%) (Table 2). Despite the lack of documentation, risk factors were very common, with patients having an average 2.22 (SD 1.61) risk factors. Only 16% had no risk factor, and 65% had two or more. The most © 2014 Wiley Publishing Asia Pty Ltd
R Gallagher et al.
752
Table 2 Cardiovascular risk factor prevalence and documentation
Table 1 Sample characteristics Characteristic (n = 142)
Overall
Age, mean (SD) Male gender, n (%) AF classification this admission Paroxysmal (< 48 h) Permanent Persistent (days/weeks) Atrial flutter AF one of multiple diagnoses on admission History of AF Chronic and comorbid conditions, n (%)† Cardiac Ischaemic heart disease Myocardial infarction PCI CABG Valve disease/surgery Heart failure Pacemaker ICD Noncardiac Respiratory disease CVA/TIA Alcohol abuse Sleep apnea Peripheral vascular disease Other (hyperthyroidism, CRF, etc.)
72.01 (12.25) 72 (51) 74 (52) 39 (28) 24 (17) 5 (4) 166 (81) 88 (62)
38 (27) 18 (13) 18 (13) 11 (8) 20 (14) 24 (17) 10 (7) 5 (4) 28 (20) 16 (11) 9 (6) 7 (5) 7 (5) 11 (8)
Characteristic (n = 142)
Overall, n (%)
Not documented, n (%)
Hypertension Hypercholesterolaemia Sedentary Overweight Diabetes Smoking (current/recent) Family history CVD Depression
89 (63) 74 (52) 37 (26) 37 (26) 26 (18) 23 (16) 17 (12) 9 (6)
12 (9) 28 (20) 68 (48) 45 (32) 28 (20) 22 (16) 48 (34) 68 (48)
CVD, cardiovascular disease. Table 3 Cardiovascular risk factor reduction programme delivery and referral Programme
n (%)†
Cardiac rehabilitation Phase I Phase II Phases I and II Heart failure programme
100 (70) 35 (25) 26 (18) 18 (13)
†
Percentages do not total 100, as multiple options are possible and some values are missing.
†
Multiple diagnoses possible. AF, atrial fibrillation; CABG, coronary artery bypass graft; CRF, chronic renal failure; CVA, cerebral vascular accident; ICD, implantable cardioverter– defibrillator; PCI, percutaneous coronary intervention; TIA, transient ischaemic event.
common modifiable risk factors were hypertension (63%) and hypercholesterolaemia (52%).
Cardiovascular risk factor reduction programme delivery and referral The majority (70%) of the sample received Phase I CR; one in four patients (25%) was referred to a Phase II CR programme, and a small proportion (13%) were referred to the heart failure programme (Table 3). Fifteen per cent did not receive or were not referred to any CR or heart failure programme. Similar reasons were provided by CR staff for not delivering Phase I CR and not referring to © 2014 Wiley Publishing Asia Pty Ltd
Phase II CR, and these were that admission time was short so that they missed the patient (24% and 19%) or that the patient was being transferred or had other treatment planned (19% and 7%). Patients who were referred for Phase II CR had more risk factors than those who were not referred (2.83 vs. 2.01, P = 0.008) and were more likely to have hypercholesterolaemia (67% vs. 47%, P = 0.03), to be overweight or obese (42% vs. 21%, P = 0.014) and not to get enough exercise (39% vs. 22%, P = 0.037) (Table 4). There were differences in referral to Phase II CR for age, gender, type of AF, presence of ischaemic heart disease and other CVD risk factors. We determined the independent predictors of referral to Phase II CR using backwards logistic regression for the most parsimonious model (χ2= 20.1, P = 0.001), and there were two significant predictors. The odds of referral were decreased by having permanent AF versus other types (OR = 0.09, 95% CI
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Atrial fibrillation inpatient profile
Table 4 Comparison of patients with AF by referral to Phase II cardiac rehabilitation Characteristic
Referred (n = 36)
Not referred (n = 106)
P value†
Total risk factors, mean (SD) Age (years), mean (SD) Male gender, n (%) History of IHD, n (%) Family history of CVD, n (%) Diabetes, n (%) Hypercholesterolaemia, n (%) Hypertension, n (%) Smoker, n (%) Overweight/obese, n (%) Low exercise, n (%) Depression, n (%) AF classification, n (%) Paroxysmal AF Permanent AF Persistent AF
2.83 (1.63) 70.8 (10.19) 19 (53) 7 (19) 6 (17) 6 (17) 24 (67) 24 (67) 8 (22) 15 (42) 14 (39) 3 (8)
2.01 (1.56) 72.16 (12.5) 54 (51) 31 (29) 11 (10) 20 (19) 50 (47) 65 (61) 15 (14) 22 (21) 23 (22) 6 (6)
0.008 0.680 0.620 0.170 0.230 0.490 0.030 0.360 0.19 0.014 0.037 0.410 0.080
23 (64) 4 (11) 17 (47)
51 (48) 35 (33) 17 (16)
†
t-Test for continuous variables, chi-squared test for categorical variables. AF, atrial fibrillation; CVD, cardiovascular disease; IHD, ischaemic heart disease; SD, standard deviation.
0.01–0.78; P = 0.029) and increased with more risk factors (OR = 1.75, 95% CI 1.25–2.45; P = 0.001).
DISCUSSION Our results indicate that the majority of patients admitted to hospital with AF are older and have multiple comorbid conditions as well as many modifiable cardiovascular risk factors such as hypertension and hypercholesterolaemia. The majority of patients had paroxysmal AF, and one in four had permanent AF, so that symptoms and treatments would need to be managed in an ongoing way, further emphasising the need for support. Although the literature indicates a high prevalence of cardiovascular risk factors in people with AF, we observed that many patients were not screened for these factors. Furthermore, although the majority of AF patients received Phase I CR, the majority were not referred to Phase II programmes. Patients with more risk factors and those who did not have permanent AF were more likely to be referred to Phase II CR. Our study contributes to the mounting body of evidence that AF patients are likely to have high selfmanagement requirements because their AF is chronic and they often suffer from multiple pre-existing and contributing cardiac conditions, other comorbid diseases27,28
and age-related changes.8 AF should be considered a chronic condition, as the majority of patients hospitalised with AF had experienced AF previously, and more than one in four had permanent AF. Despite this, the main focus in the literature and international guidelines is on achieving sinus rhythm and not so much on adjusting to AF as a chronic condition.16,25 However, this focus could be misdirected, as a recent review concluded that achieving sinus rhythm in AF patients does not confer substantial benefits in terms of morbidity and mortality.16 Instead, a lifelong approach that includes prevention of thromboembolic events and attention to other comorbid conditions is likely needed. Thromboembolic event prevention is of paramount importance, as even very short episodes of AF confer high risk of thromboembolic complications.29 Other comorbid conditions can reduce HRQoL, particularly in older people who have AF.8,13,15 Despite this, AF patients report that they do not receive counselling regarding the nature of AF, AF treatment, psychosocial adjustment or self-management,11 and, as our study shows, patients with permanent AF were less likely to be referred to Phase II CR, in spite of the demonstrated benefits for supporting functional capacity and self-care.6,24,25 © 2014 Wiley Publishing Asia Pty Ltd
R Gallagher et al.
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Given that CR is also an appropriate and effective intervention for reducing the modifiable cardiovascular risk factors prevalent in this population, it would be expected that Phase I and Phase II CR would be routine. However, CR is not systematically considered or delivered to AF patients, nor do referrals occur in a standardised way, as our study and others show.24 A factor that might contribute to lack of referral is that cardiovascular risk factors do not seem to be routinely screened or documented during admission, with depression, sedentary lifestyle and overweight/obesity the factors most often neglected. Lack of screening and documentation has several potentially negative effects including limiting awareness by health professionals and patients, discussion of risk factor management and referral to Phase II CR. Patients with fewer documented risk factors in the current study were less likely to be referred to Phase II CR, and therefore they were missing out on receiving appropriate, effective treatments.30 Given the growing body of evidence for the benefits of structured exercise, such as that included in Phase II CR, for AF patients’ exercise capacity and HRQoL, this is an important deficit.14,20,22 Further research is required that tests the effectiveness of multidisciplinary CR in AF patients.
Limitations Patients who did not have a risk documented were classified as not having the risk factor, which might underestimate the prevalence of that factor, and future research should include systematic screening rather than an audit.
Conclusions and implications for practice AF patients admitted to hospital tend to be older and to have multiple health conditions and cardiovascular risk factors and are in need of assessment and support by health professionals. Systematic screening for cardiovascular risk factors should be standard practice for people with AF. People with AF need advice and support for risk factor reduction to address medication adherence and to improve HRQoL. CR services are ideal settings for implementation of a structured management programme for AF rehabilitation services and provide an untapped resource that could improve risk factors, increase HRQoL and improve medication adherence in this population. © 2014 Wiley Publishing Asia Pty Ltd
ACKNOWLEDGEMENTS We would like to acknowledge Patrick Gallagher for his contribution to data entry and manuscript revision and production. This research received no specific grant from any funding agency in the public, commercial or not-forprofit sectors. LN is supported by an NHMRC early career fellowship (APP1036763).
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