Nicole Lowres

Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies: The SEARCH-AF study

Atrial fibrillation (AF) causes a third of all strokes, but often goes undetected before stroke. Identification of unknown AF in the community and subsequent anti-thrombotic treatment could reduce stroke burden. We investigated community screening for unknown AF using an iPhone electrocardiogram (iECG) in pharmacies, and determined the cost-effectiveness of this strategy.Pharmacists performedpulse palpation and iECG recordings, with cardiologist iECG over-reading. General practitioner review/12-lead ECG was facilitated for suspected new AF. An automated AF algorithm was retrospectively applied to collected iECGs. Cost-effectiveness analysis incorporated costs of iECG screening, and treatment/outcome data from a United Kingdom cohort of 5,555 patients with incidentally detected asymptomatic AF. A total of 1,000 pharmacy customers aged ≥65 years (mean 76 ± 7 years; 44% male) were screened. Newly identified AF was found in 1.5% (95% CI, 0.8-2.5%); mean age 79 ± 6 years; all had CHA2DS2-VASc score ≥2. AF prevalence was 6.7% (67/1,000). The automated iECG algorithm showed 98.5% (CI, 92-100%) sensitivity for AF detection and 91.4% (CI, 89-93%) specificity. The incremental cost-effectiveness ratio of extending iECG screening into the community, based on 55% warfarin prescription adherence, would be

Screening to identify unknown atrial fibrillation. A systematic review.

AUD5,988 (€3,142;

Screening for Atrial Fibrillation A Report of the AF-SCREEN International Collaboration

USD4,066) per Quality Adjusted Life Year gained and

The mobile revolution—using smartphone apps to prevent cardiovascular disease

AUD30,481 (€15,993;

Screening Education And Recognition in Community pHarmacies of Atrial Fibrillation to prevent stroke in an ambulant population aged >=65 years (SEARCH-AF stroke prevention study): a cross-sectional study protocol.

USD20,695) for preventing one stroke. Sensitivity analysis indicated cost-effectiveness improved with increased treatment adherence.Screening with iECG in pharmacies with an automated algorithm is both feasible and cost-effective. The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered.

Screening for atrial fibrillation above age 65 detects an asymptomatic subset at high risk of stroke.

Atrial fibrillation (AF) is associated with a significantly increased stroke risk which is highly preventable with appropriate oral anticoagulant therapy (OAC). However, AF may be asymptomatic and unrecognised prior to stroke. We aimed to determine if single time-point screening for AF could identify sufficient numbers with previously undiagnosed AF, to be effective for stroke prevention. This is a systematic review of clinical trials, by searching electronic medical databases, reference lists and grey literature. Studies were included if they evaluated a general ambulant adult population, using electrocardiography or pulse palpation to identify AF. We identified 30 individual studies (n=122,571, mean age 64 years, 54% male) in nine countries. Participants were recruited either from general practitioner and outpatient clinics (12 studies) or population screening/community advertisements (18 studies). Prevalence of AF across all studies was 2.3% (95% CI, 2.2-2.4%), increasing to 4.4% (CI, 4.1-4.6%) in those ≥65 years (16 studies, n= 27,884). Overall incidence of previously unknown AF (14 studies, n=67,772) was 1.0% (CI, 0.89-1.04%), increasing to 1.4% (CI, 1.2-1.6%) in those ≥65 years (8 studies, n= 18,189) in whom screening setting did not influence incidence identified. Of those with previously unknown AF, 67% were at high risk of stroke.Screening can identify 1.4% of the population ≥65 years with previously undiagnosed AF. Many of those identified would be eligible for, and benefit from OAC to prevent stroke. Given this incidence, community AF screening strategies in at risk older age groups could potentially reduce the overall health burden associated with AF.

Lifestyle risk reduction interventions in atrial fibrillation: a systematic review

Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

Screening for atrial fibrillation during influenza vaccinations by primary care nurses using a smartphone electrocardiograph (iECG): A feasibility study:

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally. Mobile technology might enable increased access to effective prevention of CVDs. Given the high penetration of smartphones into groups with low socioeconomic status, health-related mobile applications might provide an opportunity to overcome traditional barriers to cardiac rehabilitation access. The huge increase in low-cost health-related apps that are not regulated by health-care policy makers raises three important areas of interest. Are apps developed according to evidenced-based guidelines or on any evidence at all? Is there any evidence that apps are of benefit to people with CVD? What are the components of apps that are likely to facilitate changes in behaviour and enable individuals to adhere to medical advice? In this Review, we assess the current literature and content of existing apps that target patients with CVD risk factors and that can facilitate behaviour change. We present an overview of the current literature on mobile technology as it relates to prevention and management of CVD. We also evaluate how apps can be used throughout all age groups with different CVD prevention needs.

Self-monitoring for atrial fibrillation recurrence in the discharge period post-cardiac surgery using an iPhone electrocardiogram.

Background Atrial fibrillation (AF) is associated with a high risk of stroke and may often be asymptomatic. AF is commonly undiagnosed until patients present with sequelae, such as heart failure and stroke. Stroke secondary to AF is highly preventable with the use of appropriate thromboprophylaxis. Therefore, early identification and appropriate evidence-based management of AF could lead to subsequent stroke prevention. This study aims to determine the feasibility and impact of a community pharmacy-based screening programme focused on identifying undiagnosed AF in people aged 65 years and older. Methods and analysis This cross-sectional study of community-based screening to identify undiagnosed AF will evaluate the feasibility of screening for AF using a pulse palpation and handheld single-lead electrocardiograph (ECG) device. 10 community pharmacies will be recruited and trained to implement the screening protocol, targeting a total of 1000 participants. The primary outcome is the proportion of people newly identified with AF at the completion of the screening programme. Secondary outcomes include level of agreement between the pharmacists and the cardiologists interpretation of the single-lead ECG; level of agreement between irregular rhythm identified with pulse palpation and with the single-lead ECG. Process outcomes related to sustainability of the screening programme beyond the trial setting, pharmacist knowledge of AF and rate of uptake of referral to full ECG evaluation and cardiology review will also be collected. Ethics and dissemination Primary ethics approval was received on 26 March 2012 from Sydney Local Health District Human Research Ethics Committee—Concord Repatriation General Hospital zone. Results will be disseminated via forums including, but not limited to, peer-reviewed publication and presentation at national and international conferences. Clinical trials registration number ACTRN12612000406808.

To Screen or Not to Screen? Examining the Arguments Against Screening for Atrial Fibrillation

Atrial fibrillation (AF) is themost common clinical arrhythmia, and increases risk of stroke 5-fold [1]. Approximately 1/6 strokes are AFrelated [2]. These cardio-embolic strokes are severe, and in 18% the underlying AF is previously undiagnosed [2] [3]. Although the occurrence of palpitations is often a guide to the presence of AF, and the symptomatic status of patients with known AF has been well described [3], the proportion of subjects with incidentally discovered AF who do not have palpitations and are therefore unlikely to present to a physician has not previously been reported. The resulting societal burden of the largely preventable strokes in unrecognized AF could be substantially reduced by screening programs to detect incidental AF and initiating appropriate thrombo-prophylaxis with oral anticoagulants (OAC). To establish whether screening for AF may be warranted, we studied an ambulatory pre-operative population, the majority of whom were scheduled for a minor procedure, to determine the prevalence of incidental AF and the symptomatic status of those with this previously undiagnosed arrhythmia. These relatively healthy ambulant subjects should be representative of the general community.Wewere particularly interested in the prevalence of asymptomatic AF in subjects aged≥65, as such individualswould be unlikely to present to a physician andwould be most likely to benefit from thrombo-prophylaxis. A routine ECG is performed in every ambulatory subject aged ≥40 years prior to elective surgery at our Hospital. All pre-admission ECGs between January–August 2011 were reviewed: charts of those in AF were examined and validated through contact with their primary care physician to determinewhether AFwas previously diagnosed or an incidental finding. We also examined pre-procedural questionnaires administered prior to the ECG, to determine symptom status, and collected demographics, co-morbidities, medications, and calculated CHADS2/CHA2DS2VASc scores [4,5]. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. Of2802ECGs reviewed,112 (4%) showedAF, and in12of these (0.4%) AF was an incidental finding. In those ≥65 years the prevalence of AF rose to 6.7% and was incidental in 0.7% (10/1459) (Table 1). The mean age of subjects with incidental AF was 71±9 and did not differ from those with known AF. All with incidental AF were male, compared to 70% with known AF (pb0.05). Only 20% of those aged≥65with incidental AF reportedpalpitations. Thisfindingmaybe explained bya relatively lowmean restingheart rate (78±14), which was virtually identical to that seen in known AF (77 ±16), despite absence of rate-controlling medication in subjects with incidental AF. Mean CHADS2/CHA2DS2VASc scores were slightly higher in thosewith known compared to incidental AF in the overall group and in those ≥65, but differences were not significant. Mean CHADS2 score in those with incidental AF aged ≥65 was 2.2±1.5, and 7/10 had CHADS2≥2. Mean CHA2DS2VASc score in those with incidental AF≥65 was 3.8±2.0 (Fig. 1). OAC were prescribed in only 65% of patients with known AF and CHADS2≥2, consistent with the known evidence– practice gap (Table 1). Our screening of an otherwise relatively healthy ambulant population≥65 scheduled for elective predominantly minor surgery found a prevalence of 0.7% undiagnosed AF. This figure is likely an underestimate of the prevalence, and would be higher with periodic screening as a single ECG cannot detect all with paroxysmal AF. Most importantly, very few subjects reported palpitations, which is not surprising, as the resting heart was not elevated. The mean heart rate was relatively low even though no subject received heart rate slowing medications and may explain why such subjects are unlikely to present with symptoms of AF until sequelae like stroke or other thrombo-embolic manifestations occur. Understanding this phenomenon should motivate physicians to screen for AF at regular intervals, rather than wait for symptoms to occur, especially in those aged ≥65. Pulse palpation followed by a confirmatory ECG is simple, quick and may be of similar efficacy to routine ECG screening for detection of new AF in patients≥65 in general practice [6]. However, not all those with silent AF regularly visit their doctor, especially if asymptomatic, which makes a community ECG or pulse screening program potentially attractive if we are to make an impact