A Nurse-led Structured Risk Factor Management Programme to Improve Quality of Life for Patients With Atrial Fibrillation

The participants in the intervention group will receive a 12-week, structured, nurse-led risk factor management program for AF, in addition to the usual care at the study hospital.

This program, grounded in the Information-Motivation-Behavioral Skills model and Social Cognitive Theory, is designed to improve AF self-management and support sustained modification of behavioral risk factors . Delivered by a registered nurse with cardiac specialty, this program comprises 4 components:

1. A 60-minute face-to-face individual session delivered in week 1 for risk profile assessment, AF self-management education, and personalized behavioral change planning
2. Self-monitoring via self-management booklet, checklist, or smartphone step tracking according to participants' preference and capability, with progress reviewed at each contact
3. 6 bi-weekly telephone follow-up calls (Weeks 2, 4, 6, 8, 10, 12) on stages of behavioral change: behavioral initiation, early problem-solving, behavioral consolidation, behavioral maintenance, relapse prevention and transition to self-management
4. Weekly text messages sustaining participant's engagement with agreed behavioral goals.

The participants in the control group will receive the usual care provided by study hospital, comprising physician consultations and medication prescription at routine follow-up, without a structured risk factor management programme.

The 20-item AFEQT will be used to measure disease-specific health-related quality of life across four subscales: symptoms, daily activities, treatment concerns and treatment satisfaction. Each item is rated on a 7-point Likert scale. Raw scores are transformed to a 0-100 scale, with higher scores indicating better health status.

The 19-item AFSS will be used to assess patient-perceived AF symptom burden and severity. The instrument comprises two items on demographic characteristics, five items on AF disease burden (the frequency, overall severity and duration of symptomatic AF episodes), one item on global well-being, four items on AF-related healthcare utilization, and seven items on AF symptom severity. The seven AF symptom severity items are rated on a five-point Likert scale, yielding a total AFSS severity score ranging from 0 to 35, with higher scores indicating more severe symptoms.

The total distance walked in 6-minute walk test will be used to measure functional exercise capacity. Participants will be instructed to walk at their own pace along an uninterrupted 30-m corridor for 6 minutes with continuous heart rate monitoring. A longer distance indicates better functional exercise capacity.

A 10-item GSE will be used to measure individual's perceived capability to cope with stressful or challenging situations. This scale was commonly used to predict individual's behaviour, goal intentions and self-regulatory commitments, which are central in health promotion. Each item on a 4-point Likert scale and summed, with higher score indicating greater self-efficacy.

A 13-item MDS Questionnaire will be used to assess self-reported adherence to Mediterranean dietary pattern. Each item is rated dichotomously (yes/ no) and summed, with higher score indicating greater adherence.

The 7-item IPAQ-SF will be used to measure self-reported physical activity over the past week across four domains: vigorous activities, moderate activities, walking and sitting.68 Scores are expressed in metabolic equivalent of task (MET)-minutes per week, where higher values indicate higher energy expenditure.

Smoking status will be assessed by self-reporting cigarette use

Sleep duration will be assessed by self-reporting average hours of sleep per night

The 3-item AUDIT-C, a concise version of AUDIT, will be used to assess self-reported alcohol use across frequency of use, quantity of use, and frequency of health drinking. Each item is scored from 0 to 4 points, yielding a total score 0-12 with higher scores indicating greater alcohol use.

The 5-item MARS-5 will be used to assess self-reported unintentional and intentional medication adherence. Each item is rated on a 5-point Likert scale and summed, with higher score indicating better adherence.

Body mass index will be calculated as dividing body weight (kilogram) by body height (meter) squared . Body weight and height are measured by a calibrated scale and stadiometer respectively.

Systolic and diastolic blood pressure will be measured using a digital automatic blood pressure monitor with an appropriate size cuff. Participants will be asked to relax and sit quietly for 3-5 minutes before the blood pressure measurement. They will be seated with their arm supported at heart level for the measurement.

A fasting blood glucose will be assessed by a validated point-of-care device (BioHermes GluCoA1c) using a capillary blood sample obtained from a finger stick after 8 hours of fasting.

A portable point-of-care analyser (VivaDiag Lipid Testing System) will be used to measure circulating cholesterol (total cholesterol, low-density lipoprotein [LDL], high-density lipoprotein [HDL], triglycerides [TG]). Approximately 10uL of capillary blood sample will be collected at each measurement.

LE8 is a cardiovascular health score. It comprises 8 components: diet (MDS score) , physical activity (minute of moderate-intensity activity per week), nicotine exposure (self-reported use of cigarettes), sleep health (average hours of sleep per night), body mass index (kilogram/ meter^2), blood lipids (non-HDL cholesterol), blood glucose (fasting blood glucose or HbA1c for diabetes) and blood pressure (systolic and diastolic blood pressure). Each LE8 components are scored on a scale of 0 to 100 points, allowing generation of a composite cardiovascular health score which is the unweighted average of all components. Total scores range from 0 to 100 points. Higher scores correspond to better cardiovascular health.