1. Introduction
The prevalence of atrial fibrillation (AF) varies by geographic region and ethnicity, although old age is one of the main factors in the development of the arrhythmia [
1]. Old age is also a risk factor for the development of frailty syndrome (FS) [
2]. The association of AF with frailty has not been thoroughly documented; however, it has been shown that patients with AF are more likely to be diagnosed with FS [
3]. The incidence of FS in the AF population varies strongly, ranging from 5.9% to 85.5%. Additionally, FS independently predicts all-cause mortality and major bleeding in patients with AF, which can further affect the functioning of patients [
4].
Symptoms of atrial fibrillation can significantly affect functioning in daily life and reduce patients’ quality of life (HRQoL—Health Related Quality of Life) [
5]. The impact of AF on a patient’s well-being depends mainly on the frequency of attacks, the duration of the disease and the severity of symptoms. Recurrent episodes of arrhythmia result in a loss of quality of life [
6]. In addition, patients with AF have a worse QoL compared to healthy individuals [
7], which is comparable to the quality of life of patients with severe cardiovascular disease and other arrhythmias [
8]. The severity and type of AF symptoms affects not only patients’ QoL, but can also cause the development of emotional and psychological disorders. Anxiety and depressive symptoms have been shown to increase with the recurrence of arrhythmia episodes and are related to the severity of AF symptoms [
9,
10]. European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation point to the possibility of mood disorders in this population [
7]. Moreover, the presence of depressive and anxiety symptoms can affect the results of the therapeutic process in AF [
11].
Early recognition of FS is important and can support the understanding of the development of disability and dependence on others, as well as reduction in quality of life [
12,
13]. The use of HRQoL assessments indicates the disease and treatment related limitations that patients experience in their daily lives [
14], and therefore, may be helpful in choosing an appropriate treatment strategy and advising on lifestyle modifications. Few studies have evaluated or sought to explain the relationship between FS and QoL among patients with AF.
Therefore, the aim of the study was to assess symptoms of anxiety and depression and to evaluate the co-occurrence of frailty syndrome and the impact of these factors on the quality of life for in patients with AF.
4. Discussion
Symptoms and severity of atrial fibrillation can affect the onset of disability and determine the patient’s quality of life [
6]. It has also been shown that AF patients have worse QoL regardless of disease symptoms compared to patients with other cardiovascular diseases [
8]. The factors influencing HRQoL in AF are not fully understood. Studies demonstrated different results in the influence of socio-demographic factors, such as age or gender, and also of clinical factors including comorbidities, treatment or the presence of depression and anxiety symptoms [
23].
Recommendations for AF therapy articulate the need to reduce the severity of symptoms and prevent complications from the arrhythmia. The use of an appropriate AF treatment strategy is essential to improve QoL [
6]. Clinical indicators are important in assessing the effectiveness of treatment, but are currently not sufficient, and it is therefore recommended to assess HRQoL to take into account patient self-assessment [
14].
Clinical trials on intervention treatment strategies (rate or rhythm control) demonstrated lower HRQoL values for patients with AF compared to the general population or control groups [
24,
25]. The effect of the use of ablation [
26] and cardioversion [
27] on the sense of quality of life in AF has also been documented.
However, there is limited data that focuses on assessing the impact of arrhythmias on daily functioning in the general population of patients with AF and the available studies mostly use generic tools to assess QoL. The ASTA HRQoL questionnaire used in our study was designed to assess both the burden of arrhythmia-specific symptoms and their impact on HRQoL and daily functioning [
15,
18]. In our own study, the highest values, and therefore the biggest impact of AF symptoms on subjective quality of life were observed in the psychological domain, total quality of life and the physical domain. In comparison, Charitakis et al. in a study examining factors influencing arrhythmia-related symptoms and HRQoL in patients with AF reported higher quality of life scores on the ASTA questionnaire; for the overall scale (36 points), for the physical scale (38 points), and for the mental scale (28 points). This indicates an even higher burden of disease symptoms, and thus a lower rated quality of life [
28]. We can therefore conclude that there is a poor quality of life in this group of patients.
A number of factors, including symptoms of the disease, may contribute to lower quality of life of patients with AF. The most commonly reported symptoms of AF are palpitations, shortness of breath during activity, fatigue and anxiety [
29].
Such symptoms often cause AF patients to experience psychological stress, which may manifest as anxiety or depressive symptoms, leading to increased mortality and increased hospitalizations [
30]. Moreover, anxiety and depressive symptoms may worsen with each new episode of arrhythmia [
9] and are associated with increased AF symptoms and thus lower quality of life [
10].
A cross-sectional studies of 116 patients with AF indicates a significant relationship between disease symptom burden and psychological distress vs. sense of HRQoL [
31]. We obtained similar results in the present study. We showed a significant relationship between anxiety and depressive symptoms and HRQoL. Higher levels of anxiety symptoms resulted in the deterioration of quality of life in both physical and psychological domains, as well as overall quality of life. We noted similar results in the context of depressive symptoms. Higher severity of depressive symptoms negatively influenced the quality of life in patients with AF.
Patients with AF are more likely to be diagnosed with frailty syndrome. As previously mentioned, the prevalence of FS in the AF population varies widely [
4]. In this study, based on the TFI questionnaire, frailty syndrome was diagnosed in 67.24% of patients. Importantly, the co-occurrence of FS among patients with AF may be responsible for a number of adverse sequelae, including lack of or inadequate treatment with oral anticoagulants (OACs), increased risk of stroke, and increased mortality rates [
32]. Published studies found lower patient satisfaction during oral anticoagulant treatment in a population with AF with comorbid frailty syndrome, an association between the presence of anxiety and depression symptoms and the occurrence of FS [
33] and an association between the presence of anxiety and depressive symptoms and the presence of FS [
34].
There is little known about the effect of FS on HRQoL in AF [
35]. Slawuta et al. conducted an analysis of the effect of FS on HRQoL on a group of 158 patients with AF using the Edmonton Frail Scale (EFS) and ASTA HRQoL questionnaires. In the regression analysis frailty syndrome was a significant and independent factor in arrhythmia symptom severity and worsened quality of life [
35]. Likewise, in this study we observed a negative impact of FS on quality of life. The co-occurrence of FS was associated with greater limitations in overall quality of life (r = 0.38), in the psychological (r = 0.36) and the physical (r = 0.34) domains. Both the prevalence of FS and AF are significantly associated with old age. Overlapping intractable disease symptoms and FS-related changes may be responsible for reduced quality of life. In addition, FS has similar predictive power for unplanned hospitalizations, hemorrhagic complications and mortality compared to the CHA2DS2-VASc score used to assess embolic risk in AF [
36]. Understanding the relationship between frailty and quality of life may allow for a more targeted approach to the treatment and care of patients with AF and ultimately lead to better treatment outcomes in this group of patients. It is claimed that frailty can be managed in the hospital with interventions such as physiotherapy [
37], nutritional therapy [
38] and comprehensive geriatric care (CGA) [
39].
A low sense of quality of life can affect a patient’s daily functioning, but it can also be a cause of non-adherence to treatment recommendations, and therefore increased hospitalizations and deaths, with negative consequences for the health care system.
6. Implication for Practice
Both atrial fibrillation and frailty syndrome may affect patients’ sense of quality of life. Moreover, FS can have a significant impact on clinical decision-making in patients with AF. The available literature increasingly identifies frailty as a factor, prioritized over chronological age as more useful for therapeutic decision-making in AF patients. Assessment of anxiety and depressive disorders in AF patients should be the foundation for developing and implementing appropriate therapeutic interventions.
The co-occurrence of intractable atrial fibrillation symptoms with frailty syndrome and symptoms of anxiety and depression can significantly worsen the HRQoL. Therefore, it is advisable to routinely assess the quality of life itself, but also to analyze the factors that have a negative impact on the HRQoL. Therapeutic teams, which should include doctors, nurses and psychologists, should take measures aimed at improving the QoL of AF patients.