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<p><strong>BACKGROUND: </strong></p> <p>Emergency Department (ED) visit rates for patients with symptomatic, recent onset atrial fibrillation or atrial flutter (RAFF) are on the rise, which in turn has resulted in high hospital admission rates (38-45%). Optimal management strategies need to be developed for reducing hospital admission rates.</p> <p><strong>STUDY QUESTION:</strong></p> <p>The primary objective of this study is to evaluate the effectiveness of a clinical pathway for the management of low-risk RAFF patients in the ED. The hypothesis is that an evidence-based clinical pathway will help ED physicians better manage AF patients and reduce hospital admissions.</p> <p><strong>STUDY DESIGN:</strong></p> <p>A prospective, blinded, stratified, two-arm cluster-randomized trial will be conducted. The intervention is a clinical pathway for the management of RAFF.</p> <p><strong>PRIMARY AND SECONDARY OUTCOMES:</strong></p> <p>The primary outcome of this trial will be the proportion of low-risk, RAAF patients admitted to the hospital from the ED. Secondary outcomes will include a range of safety outcomes.</p> <p><strong>STATISTICAL CONSIDERATIONS:</strong></p> <p>An intention-to-treat analysis will be conducted at the individual level using proportions and means according to the variable in question with an alpha level of 0.05 and power of 0.80 for the primary outcome. The cRCT (assuming a 30% RRR) will be conducted over a two year time period. A total of 13 clusters and 3500 ED visits will be recruited to each intervention arm.</p> <p><strong>SUMMARY:</strong></p> <p>This thesis explores the methodological issues relevant to the design of a cRCT evaluating a clinical pathway in the management of acute onset, low risk AF patients presenting to the ED.</p> / Master of Science (MSc)

<p>Stroke is a devastating event for a patient. Patients undergoing cardiac surgery are at risk of both peri-operative and delayed stroke. This thesis comprises 8 chapters that highlight the rate of stroke in cardiac surgery patients and its risk predictors. It justifies the need for a randomized controlled trial of left atrial appendage (LAA) occlusion on top of usual antithrombotic therapy for stoke prevention in patients with atrial fibrillation or flutter.</p> <p>Chapter 1 is a preface that provides the rationale for undertaking each of the studies included within this thesis.</p> <p>Chapter 2 presents a large cohort study that examines the predictors of early and long-term stroke in patients undergoing cardiac surgery with emphasis on the impact of atrial fibrillation as well as the CHADS₂ score.</p> <p>Chapter 3 has been published in the journal <em>Circulation </em>in a modified form. A review of the current literature is presented, highlighting that although LAA occlusion holds promise for stroke prevention in AF, there is currently insufficient evidence that it can replace the gold standard of oral anticoagulation.</p> <p>Chapter 4 is a long-term follow-up study of the first Left Atrial Appendage Occlusion Study. This trial included patients undergoing coronary artery bypass grafting with or without AF. By performing a long-term follow-up of these patients, an estimate of stroke risk and risk of developing new AF was obtained.</p> <p>In Chapter 5, the results of LAAOS II are presented. This registry and pilot trial was used to assess the rate of recruitment into a novel design of a trial comparing LAA occlusion to antithrombotic therapy, LAA amputation safety, and the rate of a composite outcome of death, myocardial infarction, stroke, non-cerebral systemic emboli, and major bleeding.</p> <p>Chapter 6 presents the design for the LAAOS III trial. The data presented in the previous chapters is used to create the definitive trial of LAA occlusion on top of usual antithrombotic therapy using a prospective, randomized open trial with blinded end-point study (i.e., PROBE) design.</p> <p>Chapter 7 presents the health economic analysis plan for LAAOS III.</p> <p>Finally, Chapter 8 presents the conclusion, limitations, and implications of the research presented in my PhD thesis</p> / Doctor of Philosophy (PhD)

Förmaksflimmer är den vanligast förekommande arytmin och förknippas med ökad risk för stroke och hjärtsvikt samt sänkt livskvalitet. Behandlingen inriktar sig förebyggande mot stroke, frekvens- och rytmreglering samt behandling av kardiovaskulära riskfaktorer. För att klara av att leva med förmaksflimmer kan olika hanteringsstrategier underlätta samt stöd från familj och vården. Sjuksköterskans ansvar är att hjälpa de drabbade att hantera sin sjukdom samt ge rätt information. Detta kan uppnås genom personcentrerad vård som innebär att sätta personen i fokus och identifiera personliga upplevelser. Syftet med denna litteraturstudie var att beskriva personers upplevelser av att leva med förmaksflimmer.  Litteraturöversikt med strukturerad sökstrategi användes som metod. Översikten genererade 16 vetenskapliga artiklar där 15 inkluderades från sökningar i CINAHL och PubMed och en artikel inkluderades via manuell sökning. Alla artiklar kvalitetsgranskades och analyserades genom tematisk analys. Analysen genererade nio kategorier samt tre övergripande teman.  Resultatet visade att personer som lever med förmaksflimmer upplevde ansträngande symtom som påverkade dem negativt och behandlingen kunde upplevas besvärlig eller otillräcklig. De kände sig begränsade i livet och kunde inte längre göra allt som tidigare. Acceptansnivån för sjukdomen varierade och olika hanteringsstrategier förekom. Stöd var viktigt men trots det framkom brister gällande stöd både från anhöriga och vården, även förtroendet för vården varierande. Delaktighet i sin vård ansågs som viktig faktor men trots det upplevdes information- och kunskapsbrist.  Slutsatsen är att personer med förmaksflimmer upplevde varierande symtom som bidrog till fysisk och psykisk påverkan. De försökte hitta olika hanteringsstrategier men upplevde trots det begränsningar i livet. Ett ökat behov av stöd samt mer information och kunskap framkom. Det är därför viktigt att hälso- och sjukvårdspersonal besitter korrekt kunskap kring personers upplevelser av att leva med förmaksflimmer för att bidra till ökad livskvalitet genom personcentrerad vård. / Atrial fibrillation is the most common arrhythmia and is associated with an increased risk of stroke, heart failure and reduced quality of life. The treatment focuses on stroke prevention, frequency and rhythm regulation and treatment of cardiovascular risk factors. To manage living with atrial fibrillation, different strategies can facilitate as well as support from family and healthcare. The nurse's responsibility is to help them manage their illness and provide the right information which can be achieved through person-centred care by putting the person in focus and identifying personal experiences. The purpose of this literature study was to describe people's experiences of living with atrial fibrillation.  Literature review with structured search strategy was used as method. The study generated in 16 articles, 15 included from searches in CINAHL and PubMed and one was included from a manual search. All articles were quality reviewed and analyzed by thematic analysis which generated in nine categories and three overarching themes.  The results showed that people living with atrial fibrillation experienced various symptoms that affected them negatively and the treatment experienced difficult or insufficient. They felt limited and could no longer do everything as before. The level of acceptance of the disease varied and different management strategies appeared. Support was important, but despite that there were shortcomings regarding support, and trust in healthcare also varied. Participating in their care was considered an important factor but a lack of information and knowledge was experienced.  The conclusion is that people with atrial fibrillation experienced varying symptoms that contributed to physical and psychological impact and despite different coping strategies they still experienced limitations in life. An increased need for support, more information and knowledge emerged. It’s therefore important that healthcare professionals have correct knowledge about people's experiences of atrial fibrillation to increased quality of life through person-centred care.

Yes / Warfarin and direct oral anticoagulants (DOACs) have been shown to reduce the risk of stroke in patients with atrial fibrillation, yet many patients are still not being anticoagulated. This article discusses the barriers to the initiation of oral anticoagulants, in particular DOACs, and how these can be overcome.

Yes / Patients with non-valvular atrial fibrillation (AF) requiring oral anticoagulants (OAC) for stroke prevention currently have a choice of five OACs. A systematic review was undertaken to explore if patients with AF requiring an OAC for stroke prevention are involved in decision-making.

Yes / Background and Objective In England, the uptake of direct oral anticoagulants (DOACs) for stroke prevention in atrial fbrillation has been slow and varied across diferent Clinical Commissioning Groups (CCGs). This study aimed to profle the prescribing of oral anticoagulants for stroke prevention in patients with atrial fbrillation over 3 years in a CCG without restrictions to DOACs use to understand more about organisational and/or individual barriers to the early uptake of DOACs. Methods Data were collected from nine general practices between 1 April 2012 and 31 March 2015 of patients who were initiated on the oral anticoagulant therapy. Data were analysed descriptively and with independent Student’s t test and Chi square test to explore if there was an association between type of oral anticoagulant initiated and sex, age, type of prescriber and prior aspirin use. Results The early uptake of DOACs signifcantly increased over the study period (p<0.0001; medium size efect φc=0.372). There was no statistically signifcant diference between sex or age and type of oral anticoagulant initiated. Primary-care prescribers were responsible for initiating the majority of oral anticoagulants (71%; N=257) and driving the use of DOACs (72%, N=71). Patients switched from aspirin to an oral anticoagulant were more likely to be initiated on warfarin than a DOAC. Conclusions The early use of DOACs, in a CCG without restrictions to their use, was embraced by primary-care prescribers in this particular CCG. / Bayer Pharmaceuticals via an unrestricted educational grant.

Bakgrund: Förmaksflimmer (FF) är den vanligaste kroniska hjärtarytmin för människor i världen och den främsta riskfaktorn för att drabbas av sjukdomen är hög ålder. Runt 35 000 personer i Sverige drabbas årligen av FF och dagliga begränsningar orsakade av sjukdomen kan leda till nedsatt livskvalitet. Syfte: Syftet med denna litteraturstudie var att beskriva personers erfarenheter av att leva med förmaksflimmer. Metod: Sju kvalitativa artiklar och en mixed methods studie har granskats, analyserats och därefter sammanställts till denna litteraturstudie. Resultat: Tre huvudkategorier framgick i analysens resultat vilka var: ”Att uppleva fysiska och psykiska besvär”, ”Att uppleva stöd från vården som viktigt”och ”Att hantera och acceptera sin sjukdom”. Konklusion: Litteraturstudiens resultat visade att personerna med FF upplevde hur fysiska symtom påverkade deras vardagsliv negativt, att de upplevde negativa känslor av oro, rädsla, ångest och dödsångest, att de upplevde hur fysiska symtom nonchalerades av vården, att de utvecklade hanteringsstrategier och de accepterade sjukdomen. / Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults with advanced age being the most significant risk factor. Around 35 000 individuals in Sweden are afflicted by AF annually and daily limitations caused by the disease can lead to decreased quality of life. Aim: The aim of this study was to describe the experience among people living with atrial fibrillation.  Methods: Seven qualitative and one mixed methods study have been reviewed, analyzed,and then compiled for this literature study. Results: Three main categories were discovered in the result from the analysis. These three main categories were “To experience physical and psychological difficulties”, “To experience the importance of support from the healthcare” and “To cope and accept the disease”. Conclusion: In conclusion, the people with AF described experiences with physical difficulties and how they affected daily living, that they experienced negative emotions such as worry, fear, anxiety, and death anxiety, that they experienced how physical symptoms were disregarded from the healthcare, that they developed coping strategies and accepting the disease