• atrial fibrillation

Healthcare aims to provide comprehensive care that is equitable, evidence-based and person-centred for all patients. However, it is well known that cardiovascular health disparities exist in relation to gender. Significant differences have been reported in major cardiovascular conditions such as heart failure and coronary artery disease to the prejudice of women, including underrecognition of symptoms, underrepresentation in clinical trials and the provided treatment not according to evidence-based standards. At the same time, women are experiencing a lower quality of life and more symptoms of anxiety and depression compared with men. However, with the paradox of women, especially in the heart failure population, demonstrating better survival. Evidence in atrial fibrillation (AF) reports similar conclusions, demonstrating underrecognition of symptoms and disparities in treatment options such that rhythm control strategies will less likely be applied in women compared with men.1 AF being considered the most prevalent heart rhythm disorder, however, can potentially cause significant symptoms requiring application of rate and/or rhythm control strategies in patients.

Clinical symptoms are key in therapeutic decision making; symptoms may trigger patients to contact or visit a healthcare professional for diagnostic check-up, and pharmaceutical or interventional treatment is often based on the symptoms expressed by the patient. This is often the case in the management of AF. The European Society of Cardiology (ESC) guidelines for the management of AF state that rate and rhythm controlling strategies are provided aiming to improve symptoms.2 Although the burden of AF can significantly differ between patients, silent or asymptomatic AF is common, and in such cases AF is often undiagnosed. This raises the question whether AF therapy should be determined primarily on symptoms, and what the role of patient-reported outcome measures (PROMs) should be within decision making.

PROMs are those health outcomes directly reported by the patient who experienced it. In fact, it is an umbrella term that covers a variety of potential measurements, but it specifically focusses on self-reporting by the patient. Such data may be collected through interviews with the patient or by means of questionnaires evaluating symptoms and aspects of well-being, health-related quality of life (HRQoL), as well as functional and emotional status in patients.

Gleasson et al have investigated the association of AF therapies and gender on patient-reported outcomes. Interestingly, their results show that the choice of therapy (ie, rate or rhythm control) is not significantly associated with the reported severity of symptom burden, but that gender demonstrated a significant influence on PROMs. As such, women with AF reported a poorer AF-related quality of life, higher anxiety and depression levels and scored lower on functional status, compared with men.3 This may indicate that assessment of symptoms alone is not sufficient to determine the therapeutic strategy and that PROMs should be considered in decision making in order to follow a holistic treatment approach.

Such an approach has recently been translated for the management of the growing global AF population. The ESC AF guidelines recommend that such an integrated care approach should be considered in the management of all AF patients. The goal of integrated care is to provide a holistic approach to care by following four major elements, including, (1) active patient involvement, (2) multidisciplinary teams, (3) the use of E-health and smart technology to support integrated care and (4) providing a comprehensive treatment approach.2 The key message of ‘patient involvement’ is that healthcare professionals should not determine the most appropriate treatment for the patient, but with the patient. It is crucial to engage with patients to identify their values, needs and preferences regarding care, to then explicate a tailored treatment strategy that fuses the individual values with guideline recommendations.4 5 Also, adherence to treatment regimen may be improved by applying shared or informed decision making, which can be considered the cornerstone of patient-centred care. However, such processes imply significant investment by both patient and healthcare professionals in terms of time and energy, as it requires continuous patient education  to invoke patient empowerment, to make them take ownership of their condition and treatment, aiming to improve adherence and self-management, as invigorated by current AF management guidelines.2

Evidence on the effectiveness of integrated care in AF is scarce and no data on gender differences are available, given the approach is relatively novel. A recent systematic review and meta-analysis in this field reported that application of such an approach is associated with significant reductions in cardiovascular hospitalisation and all-cause mortality.6 Two of the included studies reported on PROMs in terms of quality of life outcomes, however, did not demonstrate an impact on quality of life, nor at anxiety or depression at final follow-up in comparison between the application of an integrated approach and standard of care, and none specifically analysed gender aspects.7 8 Nevertheless, PROMs may provide crucial information to be used beyond symptom assessment alone. AF can result in uncomfortable experiences, may disrupt and limit daily life and consequently the patient’s well-being. Therefore, assessment of PROMs is important to identify these limitations in order to guide patients in developing strategies to maintain self-care and daily life, which may result in a reduction of AF symptom burden.9 Nevertheless, treatment should be reviewed on a regular basis, to evaluate its effectiveness, but also to potentially intervene beyond the treatment strategy (ie, checking side effects and adverse outcomes of therapy, but also evaluation of PROMs). A structured follow-up in patients commencing therapy would be ideal in this perspective.

Given that healthcare services strive for optimal value-based healthcare, underlines the significance of measuring PROMs in AF management. As a result, the International Consortium for Health Outcomes Measurement has developed a standard set of outcomes as a reference guide in clinical care delivery, including a clear focus on PROMs. These include symptom severity; HRQoL; physical, emotional and cognitive functioning; exercise tolerance; and ability to work, and were carefully selected by an advisory panel of clinicians and patients. This standard set demonstrates the significant importance to fuse assessment of symptoms, collecting clinical data , as well as PROMs, and provides a practical tool to follow in the management of AF.10

New models of care may form avenues to contribute to manage the growing AF healthcare burden. Given the projected increase in AF prevalence to global epidemic levels in the near future, there is a substantial demand on healthcare services to deliver value-based healthcare. This requires a paradigm shift in which a holistic approach with integration of significant aspects of care is being pursued, in which PROMs should be weighed alongside with gender, symptoms and other clinical parameters, in communication and collaboration with the patient, in order to determine the most optimal and tailored treatment strategy. Widespread application of such an approach is needed to handle the global AF healthcare burden. Associated research in this field may deliver crucial PROMs data, achieved by working with the patient to achieve holistic value-based healthcare.