Edinburgh Napier University

  Introduction: Atrial fibrillation (AF) is the most common abnormal sustained heart rhythm disorder and increases risk of severe disabling stroke fivefold. Those with AF are often highly co-morbid, and a previous realist review by the authors identified that psychoeducational risk factor reduction is a crucial pillar of AF care. Updated European Society of Cardiology AF guidelines (2024) recommended that comorbidity and risk factor management be a top priority for those with AF. However, cardiac rehabilitation is not available for this population. Therefore, this study aimed to build a programme theory to identify mechanisms that would underpin successful risk reduction and lifestyle modification for AF.
Methods: A sample of 16 patients diagnosed with AF were recruited via a patient support charity (Arrythmia Alliance) to take part in individual online interviews. An initial programme theory was developed based on an extensive scoping review, results from the previously published realist review on integrated AF care and underpinned by the Self-Care of Chronic Illness middle range theory. This focuses on the processes (self-care maintenance, self-care monitoring and self-care management) by which patients assess their needs, make decisions, and engage in actions to maintain or improve their health. Data were initially analysed inductively followed by deductive analysis based on the middle range theory. Retroductive reasoning was then used to refine the programme theory. NVIVO14 was used to aid data analysis.
Findings: Seven context-mechanism and outcome configurations framed within the Self-Care of Chronic Illness middle range theory were developed. These were self-care maintenance: 1) access to credible information, early support and tailored advice, 2) knowledgeable, proactive healthcare professionals who ensure patients know that exercise is safe and signpost to suitable lifestyle risk factor reduction resources, 3) health ownership created through peer support and comparison of successful lifestyle change; self-care monitoring: 4) feedback through self-monitoring of heart rate and rhythm and timely feedback from healthcare professionals, 5) self-awareness of what is happening in their bodies; and self-care management: 6) proactive in own journey and empowered to seek advice and support for lifestyle management, and 7) consistency of message from those providing AF care.
Discussion: Patients with AF felt under supported and under prioritised to manage their lifestyle. The recent guideline update, to include provision of risk reduction in this population is promising. However, limited evidence exists to support implementation. This study identified patient perspective mechanisms to create an adaptable framework from which future interventions can be designed to increase the likelihood of intervention success.
Dissemination: The realist review on integrated AF care has been presented at the European Society of Cardiology Congress (2022) and published in the European Journal of Cardiovascular Nursing (2024). The results of this study and a further realist quality study involving experts in AF care will be combined and submitted for publication.
Impact: This programme theory is currently being used to co-design a formal lifestyle risk reduction programme for AF. It has also formed the basis for a British Heart foundation grant to undertake the intervention to formally test the theory.