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Oude Wolcherink MJ, Behr CM, Pouwels XGLV, Doggen CJM, Koffijberg H. Health Economic Research Assessing the Value of Early Detection of Cardiovascular Disease: A Systematic Review. PHARMACOECONOMICS 2023; 41:1183-1203. [PMID: 37328633 PMCID: PMC10492754 DOI: 10.1007/s40273-023-01287-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Cardiovascular disease (CVD) is the most prominent cause of death worldwide and has a major impact on healthcare budgets. While early detection strategies may reduce the overall CVD burden through earlier treatment, it is unclear which strategies are (most) efficient. AIM This systematic review reports on the cost effectiveness of recent early detection strategies for CVD in adult populations at risk. METHODS PubMed and Scopus were searched to identify scientific articles published between January 2016 and May 2022. The first reviewer screened all articles, a second reviewer independently assessed a random 10% sample of the articles for validation. Discrepancies were solved through discussion, involving a third reviewer if necessary. All costs were converted to 2021 euros. Reporting quality of all studies was assessed using the CHEERS 2022 checklist. RESULTS In total, 49 out of 5552 articles were included for data extraction and assessment of reporting quality, reporting on 48 unique early detection strategies. Early detection of atrial fibrillation in asymptomatic patients was most frequently studied (n = 15) followed by abdominal aortic aneurysm (n = 8), hypertension (n = 7) and predicted 10-year CVD risk (n = 5). Overall, 43 strategies (87.8%) were reported as cost effective and 11 (22.5%) CVD-related strategies reported cost reductions. Reporting quality ranged between 25 and 86%. CONCLUSIONS Current evidence suggests that early CVD detection strategies are predominantly cost effective and may reduce CVD-related costs compared with no early detection. However, the lack of standardisation complicates the comparison of cost-effectiveness outcomes between studies. Real-world cost effectiveness of early CVD detection strategies will depend on the target country and local context. REGISTRATION OF SYSTEMATIC REVIEW CRD42022321585 in International Prospective Registry of Ongoing Systematic Reviews (PROSPERO) submitted at 10 May 2022.
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Affiliation(s)
- Martijn J Oude Wolcherink
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Carina M Behr
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Xavier G L V Pouwels
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Carine J M Doggen
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Hendrik Koffijberg
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands.
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Halahakone U, Senanayake S, McCreanor V, Parsonage W, Kularatna S, Brain D. Cost-Effectiveness of Screening to Identify Patients With Atrial Fibrillation: A Systematic Review. Heart Lung Circ 2023:S1443-9506(23)00152-X. [PMID: 37100697 DOI: 10.1016/j.hlc.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/26/2023] [Accepted: 03/29/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Screening for Atrial Fibrillation (AF) is recommended for people aged above 65 years. Screening for AF in asymptomatic individuals can be beneficial by enabling earlier diagnosis and the commencement of interventions to reduce the risk of early events, thus improving patient outcomes. This study systematically reviews the literature about the cost-effectiveness of various screening methods for previously undiagnosed AF. METHODS Four databases were searched to identify articles that are cost-effectiveness studies conducted on screening for AF published from January 2000 to August 2022. The Consolidated Health Economic Evaluation Reporting Standards 2022 checklist was used to assess the quality of the selected studies. A previously published approach was used to assess the usefulness of each study for health policy makers. RESULTS The database search yielded 799 results, with 26 articles meeting the inclusion criteria. Articles were categorised into four subgroups: (i) population screening, (ii) opportunistic screening, (iii) targeted, and (iv) mixed methods of screening. Most of the studies screened adults ≥65 years of age. Most studies were performed from a 'health care payer perspective' and almost all studies used 'not screening' as a comparator. Almost all screening methods assessed were found to be cost-effective in comparison to 'not screening'. The reporting quality varied between 58% to 89%. The majority of the studies were found to be of limited usefulness for health policy makers, as none of the studies made any clear statements about policy change or implementation direction. CONCLUSION All approaches of AF screening were found to be cost-effective compared with no screening, while opportunistic screening was found to be the optimal approach in some studies. However, screening for AF in asymptomatic individuals is context specific and likely to be cost-effective depending on the population screened, screening approach, frequency, and the duration of screening.
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Affiliation(s)
- Ureni Halahakone
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Qld, Australia.
| | - Sameera Senanayake
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Qld, Australia
| | - Victoria McCreanor
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Qld, Australia; Jamieson Trauma Institute, Royal Brisbane & Women's Hospital, Metro North Health, Brisbane, Qld, Australia
| | - William Parsonage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Qld, Australia; Royal Brisbane and Women's Hospital, Metro North Health, Brisbane, Qld, Australia; Digital Health and Informatics Directorate, Metro South Health, Brisbane, Qld, Australia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Qld, Australia
| | - David Brain
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Qld, Australia
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Chen W, Khurshid S, Singer DE, Atlas SJ, Ashburner JM, Ellinor PT, McManus DD, Lubitz SA, Chhatwal J. Cost-effectiveness of Screening for Atrial Fibrillation Using Wearable Devices. JAMA HEALTH FORUM 2022; 3:e222419. [PMID: 36003419 PMCID: PMC9356321 DOI: 10.1001/jamahealthforum.2022.2419] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/10/2022] [Indexed: 11/18/2022] Open
Abstract
Question Is population-based atrial fibrillation (AF) screening using wearable devices cost-effective? Findings In this economic evaluation of 30 million simulated individuals with an age, sex, and comorbidity profile matching the US population aged 65 years or older, AF screening using wearable devices was cost-effective, with the overall preferred strategy identified as wearable photoplethysmography, followed conditionally by wearable electrocardiography with patch monitor confirmation (incremental cost-effectiveness ratio, $57 894 per quality-adjusted life-year). The cost-effectiveness of screening was consistent across multiple scenarios, including strata of sex, screening at earlier ages, and with variation in the association of anticoagulation with risk of stroke associated with screening-detected AF. Meaning This study suggests that contemporary AF screening using wearable devices may be cost-effective. Importance Undiagnosed atrial fibrillation (AF) is an important cause of stroke. Screening for AF using wrist-worn wearable devices may prevent strokes, but their cost-effectiveness is unknown. Objective To evaluate the cost-effectiveness of contemporary AF screening strategies, particularly wrist-worn wearable devices. Design, Setting, and Participants This economic evaluation used a microsimulation decision-analytic model and was conducted from September 8, 2020, to May 23, 2022, comprising 30 million simulated individuals with an age, sex, and comorbidity profile matching the US population aged 65 years or older. Interventions Eight AF screening strategies, with 6 using wrist-worn wearable devices (watch or band photoplethysmography, with or without watch or band electrocardiography) and 2 using traditional modalities (ie, pulse palpation and 12-lead electrocardiogram) vs no screening. Main Outcomes and Measures The primary outcome was the incremental cost-effectiveness ratio, defined as US dollars per quality-adjusted life-year (QALY). Secondary measures included rates of stroke and major bleeding. Results In the base case analysis of this model, the mean (SD) age was 72.5 (7.5) years, and 50% of the individuals were women. All 6 screening strategies using wrist-worn wearable devices were estimated to be more effective than no screening (range of QALYs gained vs no screening, 226-957 per 100 000 individuals) and were associated with greater relative benefit than screening using traditional modalities (range of QALYs gained vs no screening, −116 to 93 per 100 000 individuals). Compared with no screening, screening using wrist-worn wearable devices was associated with a reduction in stroke incidence by 20 to 23 per 100 000 person-years but an increase in major bleeding by 20 to 44 per 100 000 person-years. The overall preferred strategy was wearable photoplethysmography, followed conditionally by wearable electrocardiography with patch monitor confirmation, which had an incremental cost-effectiveness ratio of $57 894 per QALY, meeting the acceptability threshold of $100 000 per QALY. The cost-effectiveness of screening was consistent across multiple scenarios, including strata of sex, screening at earlier ages (eg, ≥50 years), and with variation in the association of anticoagulation with risk of stroke in the setting of screening-detected AF. Conclusions and Relevance This economic evaluation of AF screening using a microsimulation decision-analytic model suggests that screening using wearable devices is cost-effective compared with either no screening or AF screening using traditional methods.
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Affiliation(s)
- Wanyi Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Shaan Khurshid
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey M. Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Patrick T. Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
| | - David D. McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester
| | - Steven A. Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Boston
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
| | - Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
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Schnabel RB, Marinelli EA, Arbelo E, Boriani G, Boveda S, Buckley CM, Camm AJ, Casadei B, Chua W, Dagres N, de Melis M, Desteghe L, Diederichsen SZ, Duncker D, Eckardt L, Eisert C, Engler D, Fabritz L, Freedman B, Gillet L, Goette A, Guasch E, Svendsen JH, Hatem SN, Haeusler KG, Healey JS, Heidbuchel H, Hindricks G, Hobbs FDR, Hübner T, Kotecha D, Krekler M, Leclercq C, Lewalter T, Lin H, Linz D, Lip GYH, Løchen ML, Lucassen W, Malaczynska-Rajpold K, Massberg S, Merino JL, Meyer R, Mont L, Myers MC, Neubeck L, Niiranen T, Oeff M, Oldgren J, Potpara TS, Psaroudakis G, Pürerfellner H, Ravens U, Rienstra M, Rivard L, Scherr D, Schotten U, Shah D, Sinner MF, Smolnik R, Steinbeck G, Steven D, Svennberg E, Thomas D, True Hills M, van Gelder IC, Vardar B, Palà E, Wakili R, Wegscheider K, Wieloch M, Willems S, Witt H, Ziegler A, Daniel Zink M, Kirchhof P. Early diagnosis and better rhythm management to improve outcomes in patients with atrial fibrillation: the 8th AFNET/EHRA consensus conference. Europace 2022; 25:6-27. [PMID: 35894842 PMCID: PMC9907557 DOI: 10.1093/europace/euac062] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Despite marked progress in the management of atrial fibrillation (AF), detecting AF remains difficult and AF-related complications cause unacceptable morbidity and mortality even on optimal current therapy. This document summarizes the key outcomes of the 8th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eighty-three international experts met in Hamburg for 2 days in October 2021. Results of the interdisciplinary, hybrid discussions in breakout groups and the plenary based on recently published and unpublished observations are summarized in this consensus paper to support improved care for patients with AF by guiding prevention, individualized management, and research strategies. The main outcomes are (i) new evidence supports a simple, scalable, and pragmatic population-based AF screening pathway; (ii) rhythm management is evolving from therapy aimed at improving symptoms to an integrated domain in the prevention of AF-related outcomes, especially in patients with recently diagnosed AF; (iii) improved characterization of atrial cardiomyopathy may help to identify patients in need for therapy; (iv) standardized assessment of cognitive function in patients with AF could lead to improvement in patient outcomes; and (v) artificial intelligence (AI) can support all of the above aims, but requires advanced interdisciplinary knowledge and collaboration as well as a better medico-legal framework. Implementation of new evidence-based approaches to AF screening and rhythm management can improve outcomes in patients with AF. Additional benefits are possible with further efforts to identify and target atrial cardiomyopathy and cognitive impairment, which can be facilitated by AI.
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Affiliation(s)
- Renate B Schnabel
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | | | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Polyclinic of Modena, Modena, Italy
| | - Serge Boveda
- Cardiology—Heart Rhythm Management Department, Clinique Pasteur, 45 Avenue de Lombez, 31076 Toulouse, France,Universiteit Ziekenhuis, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George's University of London, London, UK
| | - Barbara Casadei
- RDM, Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Mirko de Melis
- Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Lien Desteghe
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium,Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Søren Zöga Diederichsen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars Eckardt
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Division of Electrophysiology, Department of Cardiology and Angiology, Münster, Germany
| | | | - Daniel Engler
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Larissa Fabritz
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK,University Center of Cardiovascular Science Hamburg, Hamburg, Germany
| | - Ben Freedman
- Heart Research Institute, The University of Sydney, Sydney, Australia
| | | | - Andreas Goette
- Atrial Fibrillation Network (AFNET), Muenster, Germany,St Vincenz Hospital, Paderborn, Germany
| | - Eduard Guasch
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Karl Georg Haeusler
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Jeff S Healey
- Population Health Research Institute, McMaster University Hamilton, ON, Canada
| | - Hein Heidbuchel
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Gerhard Hindricks
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | | | - Dipak Kotecha
- University of Birmingham & University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Thorsten Lewalter
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Hospital Munich South, Department of Cardiology, Munich, Germany,Department of Cardiology, University of Bonn, Bonn, Germany
| | - Honghuang Lin
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Maja Lisa Løchen
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Wim Lucassen
- Amsterdam UMC (location AMC), Department General Practice, Amsterdam, The Netherlands
| | | | - Steffen Massberg
- Department of Cardiology, University Hospital, LMU Munich, Munich, Germany,German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Jose L Merino
- Arrhythmia & Robotic EP Unit, La Paz University Hospital, IDIPAZ, Madrid, Spain
| | | | - Lluıs Mont
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | | | - Lis Neubeck
- Arrhythmia & Robotic EP Unit, La Paz University Hospital, IDIPAZ, Madrid, Spain
| | - Teemu Niiranen
- Medtronic, Dublin, Ireland,Centre for Cardiovascular Health Edinburgh Napier University, Edinburgh, UK
| | - Michael Oeff
- Atrial Fibrillation Network (AFNET), Muenster, Germany
| | - Jonas Oldgren
- University of Turku and Turku University Hospital, Turku, Finland
| | | | - George Psaroudakis
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Helmut Pürerfellner
- School of Medicine, Belgrade University, Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Ursula Ravens
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Bayer AG, Leverkusen, Germany
| | - Michiel Rienstra
- Ordensklinikum Linz, Elisabethinen, Cardiological Department, Linz, Austria
| | - Lena Rivard
- Institute of Experimental Cardiovascular Medicine, University Hospital Freiburg, Freiburg, Germany
| | - Daniel Scherr
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ulrich Schotten
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - Dipen Shah
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Moritz F Sinner
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Amsterdam UMC (location AMC), Department General Practice, Amsterdam, The Netherlands,Royal Brompton Hospital, London, UK
| | | | - Gerhard Steinbeck
- Atrial Fibrillation Network (AFNET), Muenster, Germany,MUMC+, Maastricht, The Netherlands
| | - Daniel Steven
- Atrial Fibrillation Network (AFNET), Muenster, Germany,University Hospital of Geneva, Cardiac Electrophysiology Unit, Geneva, Switzerland
| | - Emma Svennberg
- Center for Cardiology at Clinic Starnberg, Starnberg, Germany
| | - Dierk Thomas
- Atrial Fibrillation Network (AFNET), Muenster, Germany,University Hospital Cologne, Heart Center, Department of Electrophysiology, Cologne, Germany,Karolinska Institutet, Department of Medicine Huddinge, Karolinska University Hospital, Stockholm, Sweden,Department of Cardiology, Medical University Hospital, Heidelberg, Germany
| | - Mellanie True Hills
- HCR (Heidelberg Center for Heart Rhythm Disorders), Medical University Hospital Heidelberg, Heidelberg, Germany
| | - Isabelle C van Gelder
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Burcu Vardar
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Elena Palà
- StopAfib.org, American Foundation for Women’s Health, Decatur, TX, USA
| | - Reza Wakili
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Karl Wegscheider
- Atrial Fibrillation Network (AFNET), Muenster, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Neurovascular Research Laboratory, Vall d’Hebron Institute of Research (VHIR), Autonomous University of Barcelona, Barcelona, Spain
| | - Mattias Wieloch
- Department of Cardiology and Vascular Medicine, Westgerman Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany,Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Stephan Willems
- Atrial Fibrillation Network (AFNET), Muenster, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Department of Coagulation Disorders, Skane University Hospital, Lund University, Malmö, Sweden
| | | | | | - Matthias Daniel Zink
- Asklepios Hospital St Georg, Department of Cardiology and Internal Intensive Care Medicine, Faculty of Medicine, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Paulus Kirchhof
- Corresponding author. Tel: +49 40 7410 52438; Fax: +49 40 7410 55862. E-mail address:
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Ramkumar S, Kawakami H, Wong E, Nolan M, Marwick TH. Cost-effectiveness of Screening for Paroxysmal Atrial Fibrillation in Patients undergoing Echocardiography. Intern Med J 2022; 53:760-772. [PMID: 35377542 DOI: 10.1111/imj.15769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 01/14/2022] [Accepted: 03/29/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare the cost-effectiveness of unselected electrocardiographic (ECG) screening for atrial fibrillation (AF), and selective screening based on an abnormal echocardiogram. METHODS Two strategies of portable ECG screening for AF were compared in the base case of a hypothetical asymptomatic 65-year-old man (CHA2 DS2 -VASC=3 based on hypertension and diabetes mellitus) with previous echocardiography but without a cause for AF (eg. mitral valve disease, LV dysfunction). With age-based screening (AgeScreen, 3% AF detection rate) all patients underwent ECG. With imaging-guided screening (ImagingScreen; 5% detection rate), only patients with left atrial volume (LA) ≥34ml/m2 and LA reservoir strain <34% or LV global longitudinal strain (GLS)>-18% underwent ECG screening. A Markov model was informed by published transition probabilities, costs and quality-adjusted life years (QALY). Costs, effects and incremental cost-effectiveness ratio (ICER) were assessed for each screening strategy over a 20 year period. The willingness-to-pay threshold was $53,000/QALY. RESULTS ImagingScreen dominated AgeScreen, with a lower cost ($54,823 vs $57,842) and better outcome (11.56 vs 11.52 QALY over 20 years). Monte Carlo simulation demonstrated that 61% of observations were more efficacious with ImagingScreen, with cost below willingness-to-pay. The main cost determinants were annual costs of stroke or heart failure and AF detection rates. ImagingScreen was more cost-effective for AF detection rates up to 14%, and more cost-effective across a range of annual stroke ($24,000-$102,000) and heart failure ($4,000-$12,000) costs. CONCLUSION In patients with a previous echocardiogram, AF screening of those with baseline clinical and imaging risk parameters is more cost-effective than age-based screening. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Satish Ramkumar
- Baker Heart and Diabetes Institute, Melbourne, Australia.,School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia.,Monash Heart, Monash Health, Melbourne, Australia
| | | | - Edmond Wong
- Monash Heart, Monash Health, Melbourne, Australia
| | - Mark Nolan
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Australia.,School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
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Blomström Lundqvist C, Själander S, Garcia Rodriguez LA, Åkerborg Ö, Jin G, Caleyachetty A, Huelsebeck M, Bowrin K, Schaefer B, Mahdessian H, Hofmeister L, Levin LÅ. Impact of non-adherence to direct oral anticoagulants amongst Swedish patients with non-valvular atrial fibrillation: results from a real-world cost-utility analysis. J Med Econ 2022; 25:1085-1091. [PMID: 35997241 DOI: 10.1080/13696998.2022.2116848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
AIMS A third of non-valvular atrial fibrillation (NVAF) patients are non-adherent to direct oral anticoagulants (DOACs). Estimates of the economic value of full adherence and the cost of two types of adherence improving interventions are important to healthcare planners and decision-makers. METHODS A cost-utility analysis estimated the impact of non-adherence over a 20-year horizon, for a patient cohort with a mean age of 77 years, based on data from the Stockholm Healthcare database of NVAF patients with incident stroke between 2011 and 2018. Adherence was defined using a medication possession ratio (MPR) cut-off of 90%; primary outcomes were the number of ischemic strokes and associated incremental cost-utility ratio. RESULTS Hypothetical comparisons between cohorts of 1,000 patients with varying non-adherence levels and full adherence (MPR >90%) predicted an additional number of strokes ranging from 117 (MPR = 81-90%) to 866 (MPR <60%), and years of life lost ranging from 177 (MPR = 81- 90%) to 1,318 (MPR < 60%; discounted at 3%). Chronic disease co-management intervention occurring during each DOAC prescription renewal and patient education intervention at DOAC initiation will be cost-saving to the health system if its cost is below SEK 143 and SEK 4,655, and cost-effective if below SEK 858 and SEK 28,665, respectively. CONCLUSION Adherence improving interventions for NVAF patients on DOACs such as chronic disease co-management and patient education can be cost-saving and cost-effective, within a range of costs that appear reasonable to the Swedish healthcare system.
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Affiliation(s)
- Carina Blomström Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Sara Själander
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | | | | | | | | | | | | | | | | | - Lars-Åke Levin
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Khurshid S, Chen W, Singer DE, Atlas SJ, Ashburner JM, Choi JG, Hur C, Ellinor PT, McManus DD, Chhatwal J, Lubitz SA. Comparative Clinical Effectiveness of Population-Based Atrial Fibrillation Screening Using Contemporary Modalities: A Decision-Analytic Model. J Am Heart Assoc 2021; 10:e020330. [PMID: 34476979 PMCID: PMC8649502 DOI: 10.1161/jaha.120.020330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/21/2021] [Indexed: 12/17/2022]
Abstract
Background Atrial fibrillation (AF) screening is endorsed by certain guidelines for individuals aged ≥65 years. Yet many AF screening strategies exist, including the use of wrist-worn wearable devices, and their comparative effectiveness is not well-understood. Methods and Results We developed a decision-analytic model simulating 50 million individuals with an age, sex, and comorbidity profile matching the United States population aged ≥65 years (ie, with a guideline-based AF screening indication). We modeled no screening, in addition to 45 distinct AF screening strategies (comprising different modalities and screening intervals), each initiated at a clinical encounter. The primary effectiveness measure was quality-adjusted life-years, with incident stroke and major bleeding as secondary measures. We defined continuous or nearly continuous modalities as those capable of monitoring beyond a single time-point (eg, patch monitor), and discrete modalities as those capable of only instantaneous AF detection (eg, 12-lead ECG). In total, 10 AF screening strategies were effective compared with no screening (300-1500 quality-adjusted life-years gained/100 000 individuals screened). Nine (90%) effective strategies involved use of a continuous or nearly continuous modality such as patch monitor or wrist-worn wearable device, whereas 1 (10%) relied on discrete modalities alone. Effective strategies reduced stroke incidence (number needed to screen to prevent a stroke: 3087-4445) but increased major bleeding (number needed to screen to cause a major bleed: 1815-4049) and intracranial hemorrhage (number needed to screen to cause intracranial hemorrhage: 7693-16 950). The test specificity was a highly influential model parameter on screening effectiveness. Conclusions When modeled from a clinician-directed perspective, the comparative effectiveness of population-based AF screening varies substantially upon the specific strategy used. Future screening interventions and guidelines should consider the relative effectiveness of specific AF screening strategies.
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Affiliation(s)
- Shaan Khurshid
- Cardiovascular Research Center and Cardiac Arrhythmia ServiceDivision of CardiologyMassachusetts General HospitalBostonMA
| | - Wanyi Chen
- Institute for Technology AssessmentMassachusetts General HospitalBostonMA
| | - Daniel E. Singer
- Division of General Internal MedicineMassachusetts General HospitalMA
- Department of MedicineHarvard Medical SchoolBostonMA
| | - Steven J. Atlas
- Division of General Internal MedicineMassachusetts General HospitalMA
- Department of MedicineHarvard Medical SchoolBostonMA
| | - Jeffrey M. Ashburner
- Division of General Internal MedicineMassachusetts General HospitalMA
- Department of MedicineHarvard Medical SchoolBostonMA
| | - Jin G. Choi
- University of Chicago Pritzker School of MedicineChicagoIL
| | - Chin Hur
- Department of MedicineColumbia UniversityNew YorkNY
- Department of EpidemiologyMailman School of Public HealthColumbia UniversityNew YorkNY
| | - Patrick T. Ellinor
- Cardiovascular Research Center and Cardiac Arrhythmia ServiceDivision of CardiologyMassachusetts General HospitalBostonMA
| | - David D. McManus
- Department of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Jagpreet Chhatwal
- Institute for Technology AssessmentMassachusetts General HospitalBostonMA
| | - Steven A. Lubitz
- Cardiovascular Research Center and Cardiac Arrhythmia ServiceDivision of CardiologyMassachusetts General HospitalBostonMA
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8
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Pluymaekers NAHA, Hermans ANL, van der Velden RMJ, Gawałko M, den Uijl DW, Buskes S, Vernooy K, Crijns HJGM, Hendriks JM, Linz D. Implementation of an on-demand app-based heart rate and rhythm monitoring infrastructure for the management of atrial fibrillation through teleconsultation: TeleCheck-AF. Europace 2021; 23:345-352. [PMID: 32887994 PMCID: PMC7499572 DOI: 10.1093/europace/euaa201] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/19/2020] [Indexed: 01/15/2023] Open
Abstract
During the coronavirus 2019 (COVID-19) pandemic, outpatient visits in the atrial fibrillation (AF) clinic of the Maastricht University Medical Centre (MUMC+) were transferred into teleconsultations. The aim was to develop anon-demand app-based heart rate and rhythm monitoring infrastructure to allow appropriatmanagement of AF through teleconsultation. In line with the fundamental aspects of integrated care, including actively involving patients in the care process and providing comprehensive care by a multidisciplinary team, we implemented a mobile health (mHealth) intervention to support teleconsultations with AF patients: TeleCheck-AF. The TeleCheck-AF approach guarantees the continuity of comprehensive AF management and supports integrated care through teleconsultation during COVID-19. It incorporates three important components: (i) a structured teleconsultation ('Tele'), (ii) a CE-marked app-based on-demand heart rate and rhythm monitoring infrastructure ('Check'), and (iii) comprehensive AF management ('AF'). In this article, we describe the components and implementation of the TeleCheck-AF approach in an integrated and specialized AF-clinic through teleconsultation. The TeleCheck-AF approach is currently implemented in numerous European centres during COVID-19.
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Affiliation(s)
- Nikki A H A Pluymaekers
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Astrid N L Hermans
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Rachel M J van der Velden
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Monika Gawałko
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Dennis W den Uijl
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Saskia Buskes
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Jeroen M Hendriks
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
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9
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Sciera LK, Frost L, Dybro L, Poulsen PB. The Cost-Effectiveness of One-Time Opportunistic Screening for Atrial Fibrillation in Different Age Cohorts of Inhabitants in Denmark Aged 65 Years and Above. A Markov Modelled Analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 8:177-186. [PMID: 33337469 DOI: 10.1093/ehjqcco/qcaa092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/24/2020] [Accepted: 12/03/2020] [Indexed: 11/13/2022]
Abstract
AIM The objective was to evaluate the cost-effectiveness of one-time opportunistic screening for AF in general practice in citizens aged ≥65 years in Denmark compared to a no-screening alternative following current Danish practice. METHODS AND RESULTS A decision tree and a Markov model were designed to simulate costs and quality-adjusted life years (QALYs) in a hypothetical cohort of citizens aged ≥65 years equivalent to the Danish population (1 M citizens) over the course of 19 years, using a healthcare and societal perspective. Share of detected AF patients following opportunistic screening was retrieved from a recent Danish screening study, whereas the risk stroke and bleedings in AF patients were based on population data from national registries and their associated costs was obtained from published national registry studies.The present study showed that one-time opportunistic screening for AF was more costly, but also more effective compared to a no-screening alternative. The analysis predicts that one-time opportunistic screening of all Danes aged ≥65 years potentially can identify an additional 10,300 AF patients and prevent 856 strokes in the period considered. The incremental cost of such a screening program is €56.4 M, with a total gain of 6,000 QALYs, resulting in an incremental cost-effectiveness ratio of €9,400 per QALY gained. CONCLUSION Opportunistic screening in general practice in citizens aged ≥65 years in Denmark is cost-effective compared to a willingness-to-pay threshold of €22,000. The study and its findings support a potential implementation of opportunistic screening for AF at the general practitioner level in Denmark.
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Affiliation(s)
| | - Lars Frost
- Department of Cardiology, University Research Clinic for Innovative Patient Pathways, Regional Hospital of Silkeborg, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Dybro
- Pfizer Denmark, Internal Medicine, Ballerup, Denmark
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10
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Screening for Atrial Fibrillation: Improving Efficiency of Manual Review of Handheld Electrocardiograms †. ACTA ACUST UNITED AC 2020; 2:78. [PMID: 33778802 PMCID: PMC7610434 DOI: 10.3390/ecsa-7-08195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Atrial fibrillation (AF) is a common irregular heart rhythm associated with a five-fold increase in stroke risk. It is often not recognised as it can occur intermittently and without symptoms. A promising approach to detect AF is to use a handheld electrocardiogram (ECG) sensor for screening. However, the ECG recordings must be manually reviewed, which is time-consuming and costly. Our aims were to: (i) evaluate the manual review workload; and (ii) evaluate strategies to reduce the workload. In total, 2141 older adults were asked to record their ECG four times per day for 1–4 weeks in the SAFER (Screening for Atrial Fibrillation with ECG to Reduce stroke) Feasibility Study, producing 162,515 recordings. Patients with AF were identified by: (i) an algorithm classifying recordings based on signal quality (high or low) and heart rhythm; (ii) a nurse reviewing recordings to correct algorithm misclassifications; and (iii) two cardiologists independently reviewing recordings from patients with any evidence of rhythm abnormality. It was estimated that 30,165 reviews were required (20,155 by the nurse, and 5005 by each cardiologist). The total number of reviews could be reduced to 24,561 if low-quality recordings were excluded from review; 18,573 by only reviewing ECGs falling under certain pathological classifications; and 18,144 by only reviewing ECGs displaying an irregularly irregular rhythm for the entire recording. The number of AF patients identified would not fall considerably: from 54 to 54, 54 and 53, respectively. In conclusion, simple approaches may help feasibly reduce the manual workload by 38.4% whilst still identifying the same number of patients with undiagnosed, clinically relevant AF.
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11
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Lernfelt G, Mandalenakis Z, Hornestam B, Lernfelt B, Rosengren A, Sundh V, Hansson PO. Atrial fibrillation in the elderly general population: a 30-year follow-up from 70 to 100 years of age. SCAND CARDIOVASC J 2020; 54:232-238. [PMID: 32079431 DOI: 10.1080/14017431.2020.1729399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives. There is limited knowledge of atrial fibrillation (AF) incidence among the very old. Data from longitudinal cohort studies may give us a better insight. The aim of the study was to investigate the incidence rate and prevalence of AF, as well as the impact of AF on mortality, in the general population, from 70 to 100 years of age. Design. This was a population-based prospective cohort study where three representative samples of 70-year-old men and women (n = 2,629) from the Gerontological and Geriatric Populations Studies in Gothenburg (H-70) were included between 1971 and 1982. The participants were examined at age 70 years and were re-examined repeatedly until 100 years of age. AF was diagnosed according to a 12-lead electrocardiogram (ECG) recording at baseline and follow-up examinations, from the Swedish National Patient Register (NPR), or from the Cause of Death Register. Results. The cumulative incidence of AF from 70 to 100 years of age was 65.6% for men and 52.8% for women. Mortality was significantly higher in participants with AF compared with those without, rate ratio (RR) 1.92 (95% CI 1.73-2.14). In a subgroup analysis comprising only participants with AF diagnosed by ECG at screening, the RR for death was 1.29 (95% C.I: 1.03-1.63). Conclusions. Among persons surviving to age 70, the cumulative incidence of AF was over 50% during follow-up. Mortality rate was twice as high in participants with AF compared to participants without AF. Among participants with AF first recorded at a screening examination, the increased risk was only 29%.
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Affiliation(s)
- Gustaf Lernfelt
- Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Zacharias Mandalenakis
- Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Björn Hornestam
- Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Bodil Lernfelt
- Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annika Rosengren
- Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Valter Sundh
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
| | - Per-Olof Hansson
- Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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12
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Burns RB, Zimetbaum P, Lubitz SA, Smetana GW. Should This Patient Be Screened for Atrial Fibrillation?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2019; 171:828-836. [PMID: 31791056 DOI: 10.7326/m19-1126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation (AFib) is the most common type of cardiac arrhythmia, affecting 2.7 million to 6.1 million persons in the United States. Although some persons with AFib have no symptoms, others do. For those without symptoms, AFib may be detected by 12-lead electrocardiogram (ECG), single-lead monitors (such as ambulatory blood pressure monitors and pulse oximeters), or consumer devices (such as wearable monitors and smartphones). Pulse palpation and heart auscultation also may detect AFib. In a systematic review, screening with ECG identified more new cases of AFib than no screening. Atrial fibrillation is an important cause of stroke, and without anticoagulant treatment, patients with AFib have approximately a 5-fold increased risk for stroke. The U.S. Preventive Services Task Force reviewed the benefits and harms of ECG screening for AFib in adults aged 65 years or older and found inadequate evidence that ECG identifies AFib more effectively than usual care. This conclusion is in contrast to guidelines from the European Society of Cardiology and the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand, which found that active screening for AFib in patients older than 65 years may be useful. Here, 2 cardiologists discuss the risks and benefits of screening for AFib, if and when they would recommend screening, and whether they would recommend anticoagulation for a patient with screen-detected AFib.
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Affiliation(s)
- Risa B Burns
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., P.Z., G.W.S.)
| | - Peter Zimetbaum
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., P.Z., G.W.S.)
| | - Steven A Lubitz
- Massachusetts General Hospital, Boston Massachusetts (S.A.L.)
| | - Gerald W Smetana
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., P.Z., G.W.S.)
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13
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Affiliation(s)
- Mark Lown
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, UK
- Trinity College Dublin, Ireland
| | - Patrick Moran
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, UK
- Trinity College Dublin, Ireland
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14
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Computational modeling: What does it tell us about atrial fibrillation therapy? Int J Cardiol 2019; 287:155-161. [PMID: 30803891 DOI: 10.1016/j.ijcard.2019.01.077] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 12/09/2018] [Accepted: 01/22/2019] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is a complex cardiac arrhythmia with diverse etiology that negatively affects morbidity and mortality of millions of patients. Technological and experimental advances have provided a wealth of information on the pathogenesis of AF, highlighting a multitude of mechanisms involved in arrhythmia initiation and maintenance, and disease progression. However, it remains challenging to identify the predominant mechanisms for specific subgroups of AF patients, which, together with an incomplete understanding of the pleiotropic effects of antiarrhythmic therapies, likely contributes to the suboptimal efficacy of current antiarrhythmic approaches. Computer modeling of cardiac electrophysiology has advanced in parallel to experimental research and provides an integrative framework to attempt to overcome some of these challenges. Multi-scale cardiac modeling and simulation integrate structural and functional data from experimental and clinical work with knowledge of atrial electrophysiological mechanisms and dynamics, thereby improving our understanding of AF mechanisms and therapy. In this review, we describe recent advances in our quantitative understanding of AF through mathematical models. We discuss computational modeling of AF mechanisms and therapy using detailed, mechanistic cell/tissue-level models, including approaches to incorporate variability in patient populations. We also highlight efforts using whole-atria models to improve catheter ablation therapies. Finally, we describe recent efforts and suggest future extensions to model clinical concepts of AF using patient-level models.
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