Mind the gap: Deficits in fundamental disease-specific knowledge in atrial fibrillation


      • Individuals with atrial fibrillation had limited disease-specific knowledge.
      • Most participants overestimated their risk of stroke from 15 to 50%.
      • Deficits in patient knowledge were attenuated slightly by education but not income.
      • Patients require enhanced AF knowledge to participate in shared decision making.



      Patient success with atrial fibrillation (AF) requires adequate health literacy to understand the disease and rationale for treatment. We hypothesized that individuals receiving treatment for AF would have increased knowledge about AF and that such knowledge would be modified by education and income.


      We enrolled adults with AF receiving anticoagulation at ambulatory clinic sites. Participants responded to survey items encompassing the definitions of AF and stroke, the rationale for anticoagulation, and an estimation of their annual stroke risk. We examined responses in relation to household income and education in multivariable-adjusted models.


      We enrolled 339 individuals (age 72.0 ± 10.1; 43% women) with predominantly lower annual income ($20–49,999, n = 99, 29.2%) and a range of educational attainment (high school or vocational, n = 117, 34.5%). Participants demonstrated moderate AF knowledge (1.7 ± 0.6; range 0–2) but limited knowledge about anticoagulation (1.3 ± 0.7; range 0–3) or stroke (1.5 ± 0.8; range 0–3). Income was not associated with improvement in AF (P = 0.32 for trend), anticoagulation (P = 0.27) or stroke knowledge (P = 0.26). Individuals with bachelor or graduate degree had greater AF (1.8 ± 0.5) and stroke (1.6 ± 0.8) knowledge relative to those with high school or vocational training (1.4 ± 0.7 and 1.2 ± 0.9; P ≪ 0.01, both estimates). Education was not associated with understanding the rationale for anticoagulation. Most participants (230, 68%) estimated their annual stroke risk as ≥15%.


      We identified consistent, fundamental gaps in disease-specific knowledge in a cohort of adults receiving treatment for non-valvular AF. Improved patient understanding of this complex and chronic disease may enhance shared decision making, patient engagement, anticoagulation adherence, and clinical outcomes in AF.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to International Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Reiffel J.A.
        Atrial fibrillation and stroke: epidemiology.
        Am. J. Med. 2014; 127: e15-e16
        • January C.T.
        • Wann L.S.
        • Calkins H.
        • Chen L.Y.
        • Cigarroa J.E.
        • Cleveland Jr, J.C.
        • Ellinor P.T.
        • Ezekowitz M.D.
        • Field M.E.
        • Furie K.L.
        • Heidenreich P.A.
        • Murray K.T.
        • Shea J.B.
        • Tracy C.M.
        • Yancy C.W.
        2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation.
        J. Am. Coll. Cardiol. 2019; 74: 104-132
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • Calkins H.
        • Cigarroa J.E.
        • Cleveland Jr., J.C.
        • Conti J.B.
        • Ellinor P.T.
        • Ezekowitz M.D.
        • Field M.E.
        • Murray K.T.
        • Sacco R.L.
        • Stevenson W.G.
        • Tchou P.J.
        • Tracy C.M.
        • Yancy C.W.
        • Members A.A.T.F.
        2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
        Circulation. 2014; 130: e199-e267
        • Aliot E.
        • Breithardt G.
        • Brugada J.
        • Camm J.
        • Lip G.Y.
        • Vardas P.E.
        • Wagner M.
        An international survey of physician and patient understanding, perception, and attitudes to atrial fibrillation and its contribution to cardiovascular disease morbidity and mortality.
        Europace. 2010; 12: 626-633
        • Fang M.C.
        • Panguluri P.
        • Machtinger E.L.
        • Schillinger D.
        Language, literacy, and characterization of stroke among patients taking warfarin for stroke prevention: implications for health communication.
        Patient Educ. Couns. 2009; 75: 403-410
        • Reading S.R.
        • Go A.S.
        • Fang M.C.
        • Singer D.E.
        • Liu I.A.
        • Black M.H.
        • Udaltsova N.
        • Reynolds K.
        Health literacy and awareness of atrial fibrillation.
        J. Am. Heart Assoc. 2017; 6
        • Desteghe L.
        • Engelhard L.
        • Raymaekers Z.
        • Kluts K.
        • Vijgen J.
        • Dilling-Boer D.
        • Koopman P.
        • Schurmans J.
        • Dendale P.
        • Heidbuchel H.
        Knowledge gaps in patients with atrial fibrillation revealed by a new validated knowledge questionnaire.
        Int. J. Cardiol. 2016; 223: 906-914
        • Lane D.A.
        • Meyerhoff J.
        • Rohner U.
        • Lip G.Y.H.
        Atrial fibrillation patient preferences for oral anticoagulation and stroke knowledge: results of a conjoint analysis.
        Clin. Cardiol. 2018; 41: 855-861
        • Hernandez Madrid A.
        • Potpara T.S.
        • Dagres N.
        • Chen J.
        • Larsen T.B.
        • Estner H.
        • Todd D.
        • Bongiorni M.G.
        • Sciaraffia E.
        • Proclemer A.
        • Cheggour S.
        • Amara W.
        • Blomstrom-Lundqvist C.
        Differences in attitude, education, and knowledge about oral anticoagulation therapy among patients with atrial fibrillation in Europe: result of a self-assessment patient survey conducted by the European Heart Rhythm Association.
        Europace. 2016; 18: 463-467
        • Aronis K.N.
        • Edgar B.
        • Lin W.
        • Martins M.A.P.
        • Paasche-Orlow M.K.
        • Magnani J.W.
        Health literacy and atrial fibrillation: relevance and future directions for patient-centred care.
        Eur Cardiol. 2017; 12: 52-57
        • Gazmararian J.A.
        • Williams M.V.
        • Peel J.
        • Baker D.W.
        Health literacy and knowledge of chronic disease.
        Patient Educ. Couns. 2003; 51: 267-275
        • Oramasionwu C.U.
        • Bailey S.C.
        • Duffey K.E.
        • Shilliday B.B.
        • Brown L.C.
        • Denslow S.A.
        • Michalets E.L.
        The association of health literacy with time in therapeutic range for patients on warfarin therapy.
        J. Health Commun. 2014; 19: 19-28
        • Rolls C.A.
        • Obamiro K.O.
        • Chalmers L.
        • Bereznicki L.R.E.
        The relationship between knowledge, health literacy, and adherence among patients taking oral anticoagulants for stroke thromboprophylaxis in atrial fibrillation.
        Cardiovasc. Ther. 2017; 35
        • Guhl E.
        • Althouse A.
        • Sharbaugh M.
        • Pusateri A.M.
        • Paasche-Orlow M.
        • Magnani J.W.
        Association of income and health-related quality of life in atrial fibrillation.
        Open Heart. 2019; 6e000974
        • Lip G.Y.
        • Nieuwlaat R.
        • Pisters R.
        • Lane D.A.
        • Crijns H.J.
        Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation.
        Chest. 2010; 137: 263-272
        • Hendriks J.M.L.
        • Crijns H.J.G.M.
        • Tieleman R.G.
        • Vrijhoef H.J.M.
        The atrial fibrillation knowledge scale: development, validation and results.
        Int. J. Cardiol. 2013; 168: 1422-1428
        • OECD Skills Studies
        Time for the U.S. to Reskill?: What the Survey of Adult Skills Says.
        2019 (Accessed on April 27)
        • Magnani J.W.
        • Mujahid M.S.
        • Aronow H.D.
        • Cene C.W.
        • Dickson V.V.
        • Havranek E.
        • Morgenstern L.B.
        • Paasche-Orlow M.K.
        • Pollak A.
        • Willey J.Z.
        Health literacy and cardiovascular disease: fundamental relevance to primary and secondary prevention: a scientific statement from the American Heart Association.
        Circulation. 2018; 138: e48-e74
        • Institute of Medicine (U.S.). Committee on Quality of Health Care in America
        Crossing the Quality Chasm: A New Health System for the 21st Century.
        National Academy Press, Washington, D.C.2001
        • Seaburg L.
        • Hess E.P.
        • Coylewright M.
        • Ting H.H.
        • McLeod C.J.
        • Montori V.M.
        Shared decision making in atrial fibrillation: where we are and where we should be going.
        Circulation. 2014; 129: 704-710
        • Tuckett D.A.
        • Boulton M.
        • Olson C.
        A new approach to the measurement of patients' understanding of what they are told in medical consultations.
        J. Health Soc. Behav. 1985; 26: 27-38
        • Barry M.J.
        • Edgman-Levitan S.
        Shared decision making--pinnacle of patient-centered care.
        N. Engl. J. Med. 2012; 366: 780-781