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Frost L, Johnsen SP, Benjamin EJ, Trinquart L, Vinter N. Social drivers in atrial fibrillation occurrence, screening, treatment, and outcomes: systematic-narrative hybrid review. Eur Heart J Suppl 2024; 26:iv50-iv60. [PMID: 39099579 PMCID: PMC11292415 DOI: 10.1093/eurheartjsupp/suae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
The importance of social drivers of health (SDOH) in the occurrence, detection, treatment, and outcome of atrial fibrillation (AF) has attracted increasing attention. Addressing SDOH factors may suggest opportunities to prevent AF and its complications. We aimed to conduct a structured narrative review and summarize current knowledge on the association between race and ethnicity, SDOH, including rural vs. urban habitation, education, income, and neighbourhood, and the risk of AF, its management, and complications. We identified 537 references in PubMed and 473 references in Embase. After removal of duplicates, we screened the abstracts of 975 references, resulting in 113 references that were examined for eligibility. Subsequently, 34 references were excluded leaving 79 references for the review. Evidence of a social gradient in AF incidence and prevelance were conflicting. However, we found substantial evidence indicating social inequities in the detection of AF, access to treatment, and outcomes such as healthcare utilization, bleeding, heart failure, stroke, dementia, work disability, and death. Inequities are reported across various health care systems and constitute a global problem affecting several continents, although data from Africa and South America are lacking. Given the documented social inequities in AF detection, management, and outcomes, there is an urgent need for healthcare systems, policymakers, and society to identify and implement effective interventions that can reduce inequities and improve outcomes in individuals with AF.
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Affiliation(s)
- Lars Frost
- Department of Cardiology, Diagnostic Centre, University Clinic for Development of Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 1, 8600 Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Søren Paaske Johnsen
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Selma Lagerløfs Vej 249, 9260 Gistrup, Denmark
| | - Emelia J Benjamin
- Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, 715 Albany St, Boston, MA 02118, USA
- Department of Epidemiology, Boston University School of Public Health, 715 Albany St, Boston, MA 02118, USA
| | - Ludovic Trinquart
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Selma Lagerløfs Vej 249, 9260 Gistrup, Denmark
- Tufts Clinical and Translational Science Institute, Tufts University, 35 Kneeland St, Boston, MA 02111, USA
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Boston, MA 0211, USA
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, USA
| | - Nicklas Vinter
- Department of Cardiology, Diagnostic Centre, University Clinic for Development of Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 1, 8600 Silkeborg, Denmark
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Selma Lagerløfs Vej 249, 9260 Gistrup, Denmark
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van der Velden RMJ, Bonander C, Crijns HJGM, Kemp-Gudmundsdottir K, Engdahl J, Linz D, Svennberg E. Adherence to a handheld device-based atrial fibrillation screening protocol is associated with clinical outcomes. Heart 2024; 110:626-634. [PMID: 38182278 DOI: 10.1136/heartjnl-2023-323522] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/12/2023] [Indexed: 01/07/2024] Open
Abstract
OBJECTIVE To evaluate adherence and adherence consistency to the handheld ECG device-based screening protocol and their association with adverse cerebral and cardiovascular outcomes in two systematic atrial fibrillation (AF) screening programmes. METHODS In 2012 (Systematic ECG Screening for Atrial Fibrillation Among 75-Year Old Subjects in the Region of Stockholm and Halland, Sweden (STROKESTOP) study) and 2016 (Stepwise mass screening for atrial fibrillation using N-terminal pro b-type natriuretic peptide (STROKESTOP II) study), half of all 75- and 76-year-old inhabitants of up to two Swedish regions were invited to participate in a systematic AF screening programme. Participants were instructed to perform 30-second measurements twice daily in STROKESTOP and four times daily in STROKESTOP II for 2 weeks. Adherence was defined as the number of measurements performed divided by the number of measurements asked, whereas adherence consistency was defined as the number of days with complete registrations. RESULTS In total, 6436 participants (55.7% female) from STROKESTOP and 3712 (59.8% female) from STROKESTOP II were included. Median adherence and adherence consistency were 100 (92-100)% and 12 (11-13) days in STROKESTOP and 90 (75-98)% and 8 (3-11) days in STROKESTOP II. Female sex and lower education were factors associated with both optimal adherence and adherence consistency in both studies. In STROKESTOP, low adherence and adherence consistency were associated with higher risk of adverse cerebral and cardiovascular outcomes (HR for composite primary endpoint 1.30 (1.11 to 1.51), p=0.001), including stroke (HR 1.68 (1.22 to 2.32), p=0.001) and dementia (1.67 (1.27 to 2.19), p<0.001). CONCLUSIONS Adherence to twice daily handheld ECG measurements in STROKESTOP was higher than to four times daily measurements in STROKESTOP II. Female sex and lower educational attainment were associated with ≥100% adherence and adherence consistency. Low adherence and adherence consistency were associated with a higher risk of adverse outcomes.
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Affiliation(s)
- Rachel M J van der Velden
- Department of Cardiology, Maastricht University Medical Centre+ and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Carl Bonander
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Goteborg, Sweden
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre+ and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | | | - Johan Engdahl
- Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Centre+ and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
- Department of Biomedical Sciences, University of Copenhagen, Kobenhavn, Denmark
- Center for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Emma Svennberg
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
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Mant J, Modi RN, Charlton P, Dymond A, Massou E, Brimicombe J, Freedman B, Griffin SJ, Hobbs FDR, Lip GYH, McManus RJ, Williams K. The feasibility of population screening for paroxysmal atrial fibrillation using hand-held electrocardiogram devices. Europace 2024; 26:euae056. [PMID: 38411621 PMCID: PMC10946414 DOI: 10.1093/europace/euae056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/22/2024] [Indexed: 02/28/2024] Open
Abstract
AIMS There are few data on the feasibility of population screening for paroxysmal atrial fibrillation (AF) using hand-held electrocardiogram (ECG) devices outside a specialist setting or in people over the age of 75. We investigated the feasibility of screening when conducted without face-to-face contact ('remote') or via in-person appointments in primary care and explored impact of age on screening outcomes. METHODS AND RESULTS People aged ≥65 years from 13 general practices in England participated in screening during 2019-20. This involved attending a practice nurse appointment (10 practices) or receiving an ECG device by post (three practices). Participants were asked to use a hand-held ECG for 1-4 weeks. Screening outcomes included uptake, quality of ECGs, AF detection rates, and uptake of anticoagulation if AF was detected. Screening was carried out by 2141 (87.5%) of people invited to practice nurse-led screening and by 288 (90.0%) invited to remote screening. At least 56 interpretable ECGs were provided by 98.0% of participants who participated for 3 weeks, with no significant differences by setting or age, except people aged 85 or over (91.1%). Overall, 2.6% (64/2429) screened participants had AF, with detection rising with age (9.2% in people aged 85 or over). A total of 53/64 (82.8%) people with AF commenced anticoagulation. Uptake of anticoagulation did not vary by age. CONCLUSION Population screening for paroxysmal AF is feasible in general practice and without face-to-face contact for all ages over 64 years, including people aged 85 and over.
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Affiliation(s)
- Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
| | - Rakesh N Modi
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
| | - Peter Charlton
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
| | - Andrew Dymond
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
| | - Efthalia Massou
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
| | - James Brimicombe
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
| | - Ben Freedman
- Heart Research Institute, University of Sydney, Room 3114, Level 3 East, D17 - Charles Perkins Centre, Sydney, NSW 2006, Australia
| | - Simon J Griffin
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0SL, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Kate Williams
- Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, 2 Worts’ Causeway, Cambridge CB1 8RN, UK
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Etminani F, Sandgren E, Holm J, Magnusson P, Modica A, Moberg K, Davidsson T, Stalpe L, Kiflemariam S, Younan N, Parikh P, Wadhwa M, Sundin A, Engdahl J. Randomised, siteless study to compare systematic atrial fibrillation screening using enrichment by a risk prediction model with standard care in a Swedish population aged ≥ 65 years: CONSIDERING-AF study design. BMJ Open 2024; 14:e080639. [PMID: 38216189 PMCID: PMC10806481 DOI: 10.1136/bmjopen-2023-080639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/22/2023] [Indexed: 01/14/2024] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common arrhythmia and confers an increased risk of mortality, stroke, heart failure and cognitive decline. There is growing interest in AF screening; however, the most suitable population and device for AF detection remains to be elucidated. Here, we present the design of the CONSIDERING-AF (deteCtiON and Stroke preventIon by moDEl scRreenING for Atrial Fibrillation) study. METHODS AND ANALYSIS CONSIDERING-AF is a randomised, controlled, siteless, non-blinded diagnostic superiority trial with four parallel groups and a primary endpoint of identifying AF during a 6-month study period set in Region Halland, Sweden. In each group, 740 individuals aged≥65 years will be included. The primary objective is to compare the intervention of AF screening enrichment using a risk prediction model (RPM), followed by 14 days of a continuous ECG patch, with no intervention (standard care). Primary outcome is defined as the incident AF recorded in the Region Halland Information Database after 6 months as compared with standard care. Secondary endpoints include the difference in incident AF between groups enriched or not by the RPM, with and without an invitation to 14 days of continuous ECG recording, and the proportions of oral anticoagulation treatment in the four groups. ETHICS AND DISSEMINATION This study has ethical approval from the Swedish Ethical Review Authority. Results will be published in peer-reviewed international journals. TRIAL REGISTRATION NUMBER NCT05838781.
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Affiliation(s)
- Farzaneh Etminani
- Center for Applied Intelligent Systems Research in Health (CAISR Health), Halmstad University, Halmstad, Sweden
- Department of Research and Development (FoU), Region Halland, Halmstad, Sweden
| | - Emma Sandgren
- Department of Medicine, Hallands sjukhus Varberg, Varberg, Sweden
| | | | | | | | | | | | | | | | - Ninia Younan
- Department of Medicine, Hallands sjukhus Varberg, Varberg, Sweden
| | - Purvee Parikh
- Medical Affairs, Philips, Ambulatory Monitoring and Diagnostics, San Diego, California, USA
| | - Manish Wadhwa
- Medical Affairs, Philips, Ambulatory Monitoring and Diagnostics, San Diego, California, USA
| | | | - Johan Engdahl
- Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
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Nilsson A, Strömberg U, Björk J, Forsberg A, Fritzell K, Kemp Gudmundsdottir KR, Engdahl J, Bonander C. Examining the continuum of resistance model in two population-based screening studies in Sweden. Prev Med Rep 2023; 35:102317. [PMID: 37519442 PMCID: PMC10372382 DOI: 10.1016/j.pmedr.2023.102317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/20/2023] [Accepted: 07/08/2023] [Indexed: 08/01/2023] Open
Abstract
In studies recruited on a voluntary basis, lack of representativity may impair the ability to generalize findings to the target population. Previous studies, primarily based on surveys, have suggested that generalizability may be improved by exploiting data on individuals who agreed to participate only after receiving one or several reminders, as such individuals may be more similar to non-participants than what early participants are. Assessing this idea in the context of screenings, we compared sociodemographic characteristics and health across early, late, and non-participants in two large population-based screening studies in Sweden: STROKESTOP II (screening for atrial fibrillation; 6,867 participants) and SCREESCO (screening for colorectal cancer; 39,363 participants). We also explored the opportunities to reproduce the distributions of characteristics in the full invited populations, either by assuming that the non-participants were similar to the late participants, or by applying a linear extrapolation model based on both early and late participants. Findings showed that early and late participants exhibited similar characteristics along most dimensions, including civil status, education, income, and health examination results. Both these types of participants in turn differed from the non-participants, with fewer married, lower educational attainments, and lower incomes. Compared to early participants, late participants were more likely to be born outside of Sweden and to have comorbidities, with non-participants similar or even more so. The two empirical models improved representativity in some cases, but not always. Overall, we found mixed support that data on late participation may be useful for improving representativeness of screening studies.
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Affiliation(s)
- Anton Nilsson
- Epidemiology, Population Studies and Infrastructures (EPI@LUND), Lund University, Lund, Sweden
| | - Ulf Strömberg
- Region Halland, Halmstad, Sweden
- Health Economics and Policy, School of Public Health & Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Jonas Björk
- Epidemiology, Population Studies and Infrastructures (EPI@LUND), Lund University, Lund, Sweden
- Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden
| | - Anna Forsberg
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Kaisa Fritzell
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden
- The Hereditary Cancer Clinic, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | | | - Johan Engdahl
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Carl Bonander
- Health Economics and Policy, School of Public Health & Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Centre for Societal Risk Research, Karlstad University, Sweden
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