Atrial fibrillation: is there enough evidence to recommend opportunistic or systematic screening?

Increasing screening for atrial fibrillation in general practice: the Atrial Fibrillation Self-Screening, Management And guideline-Recommended Therapy (AF Self-SMART) study

OBJECTIVE

To assess whether atrial fibrillation (AF) self-screening stations in general practice waiting rooms improve AF screening, diagnosis, and stroke risk management.

DESIGN, SETTING

Intervention study (planned duration: twelve weeks) in six New South Wales general practices (two in rural locations, four in greater metropolitan Sydney), undertaken during 28 August 2020 - 5 August 2021.

PARTICIPANTS

People aged 65 years or more who had not previously been diagnosed with AF, and had appointments for face-to-face GP consultations. People with valvular AF were excluded.

INTERVENTION

AF self-screening station and software, integrated with practice electronic medical record programs, that identified and invited participation by eligible patients, and exported single-lead electrocardiograms and automated evaluations to patients' medical records.

MAIN OUTCOME MEASURES

Screening rate; incidence of newly diagnosed AF during intervention and pre-intervention periods; prescribing of guideline-recommended anticoagulant medications.

RESULTS

Across the six participating practices, 2835 of 7849 eligible patients (36.1%) had face-to-face GP appointments during the intervention period, of whom 1127 completed AF self-screening (39.8%; range by practice: 12-74%). AF was diagnosed in 49 screened patients (4.3%), 44 of whom (90%) had CHA₂ DS₂ -VA scores of 2 or more (high stroke risk). The incidence of newly diagnosed AF during the pre-intervention period was 11 cases per 1000 eligible patients; during the intervention period, it was 22 per 1000 eligible patients (screen-detected: 17 per 1000 eligible patients; otherwise detected: 4.6 per 1000 eligible patients). Prescribing of oral anticoagulation therapy for people newly diagnosed with AF and high stroke risk was similar during the pre-intervention (20 of 24, 83%) and intervention periods (46 of 54, 85%).

CONCLUSIONS

AF self-screening in general practice waiting rooms is a feasible approach to increasing AF screening and diagnosis rates by reducing time barriers to screening by GPs. AF self-screening could reduce the number of AF-related strokes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12620000233921 (prospective).

2021 Asia Pacific Heart Rhythm Society (APHRS) practice guidance on atrial fibrillation screening

In this paper, the Asia Pacific Heart Rhythm Society (APHRS) sought to provide practice guidance on AF screening based on recent evidence, with specific considerations relevant to the Asia-Pacific region. A key recommendation is opportunistic screening for people aged ≥65 years (all countries), with systematic screening to be considered for people aged ≥75 years or who have additional risk factors (all countries).

Exploring stroke risk and prevention in China: insights from an outlier

In contrast to the declining trend in most regions worldwide, the incidence of stroke is increasing in China and is leading to an alarming burden for the national healthcare system. In this review, we have generated new insights from this outlier, and we aim to provide new information that will help decrease the global stroke burden, especially in China and other regions sharing similar problems with China. First of all, several unsolved aspects fundamentally accounting for this discrepancy were promising, including the serious situation of hypertension management, underdiagnosis of atrial fibrillation and underuse of anticoagulants, and unhealthy lifestyles (e.g., heavy smoking). In addition, efforts for further alleviating the incidence of stroke were recommended in certain fields, including targeted antiplatelet regimes and protections from cold wave-related stroke. Furthermore, advanced knowledge about cancer-related strokes, recurrent strokes and the status preceding stroke onset that we called stroke-prone status herein, is required to properly mitigate patient stroke risk, and to provide improved outcomes for patients after a stroke has occurred.

eHealth Tools to Provide Structured Assistance for Atrial Fibrillation Screening, Management, and Guideline-Recommended Therapy in Metropolitan General Practice: The AF - SMART Study

Background

This eHealth implementation study aimed to evaluate strategies to promote opportunistic atrial fibrillation (AF) screening using electronic screening prompts and improve treatment using electronic decision support (EDS) software.

Methods and Results

An electronic screening prompt appeared whenever an eligible patient's (aged ≥65 years, no AF diagnosis) medical record was opened in participating general practices. General practitioners and practice nurses offered screening using a smartphone ECG, with validated AF algorithm. Guideline‐based EDS was provided to assist treatment decisions. Deidentified data were collected from practices using a data extraction tool. General practices (n=8) across Sydney, Australia, screened for a median of 6 months. A total of 1805 of 11 476 (16%) eligible patients who attended were screened (44% men, mean age 75.7 years). Screening identified 19 (1.1%) new cases of AF (mean age, 79 years; mean CHA₂DS₂‐VASc, 3.7; 53% men). General practitioners (n=30) performed 70% of all screenings (range 1–448 patients per general practitioner). The proportion of patients with AF who had CHA₂DS₂‐VASc ≥2 for men or ≥3 for women prescribed oral anticoagulants was higher for those diagnosed during the study: 15 of 18 (83%) for screen‐detected and 39 of 46 (85%) for clinically detected, compared with 933 of 1306 (71%) patients diagnosed before the study (P<0.001). The EDS was accessed 111 times for patients with AF and for 4 of 19 screen‐detected patients.

Conclusions

The eHealth tools showed promise. Adherence to guideline‐based oral anticoagulant prescription was significantly higher in patients diagnosed during the study period, although the EDS was only used in a minority. While the proportion of eligible patients screened and EDS use was relatively low, further refinements may improve uptake in clinical practice.

Clinical Trial Registration

URL: www.anzctr.org.au. Unique identifier: ACTRN12616000850471.