S. B. Freedman

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;

Choice of secondary prevention improves risk factors after acute coronary syndrome: 1-year follow-up of the CHOICE (Choice of Health Options In prevention of Cardiovascular Events) randomised controlled trial

USD4,066) per Quality Adjusted Life Year gained and

Elevated circulating levels of matrix metalloproteinase‐9 and ‐2 in patients with symptomatic coronary artery disease

AUD30,481 (€15,993;

Effect of heart rate reduction by ivabradine on left ventricular remodeling in the echocardiographic substudy of BEAUTIFUL

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.

Four-year follow-up of the Choice of Health Options In prevention of Cardiovascular Events randomized controlled trial

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.

Patient-centered modular secondary prevention following acute coronary syndrome: A randomized controlled trial

Objective: To determine the effect of a new CHOICE (Choice of Health Options In prevention of Cardiovascular Events) programme on cardiovascular risk factors in acute coronary syndrome (ACS) survivors. Design: Single-blind randomised controlled trial. Setting: Tertiary referral hospital in Sydney Australia. Patients: 144 ACS survivors who were not accessing standard cardiac rehabilitation. Data were also collected on a further 64 ACS survivors attending standard cardiac rehabilitation. Intervention: The CHOICE group (n = 72) participated in a brief, patient-centred, modular programme comprising a clinic visit plus telephone support, encompassing mandatory cholesterol lowering and tailored preferential risk modification. The control group (n = 72) participated in continuing conventional care but no centrally coordinated secondary prevention. Main outcome measures: Values for total cholesterol, systolic blood pressure, smoking status and physical activity. Results: CHOICE and control groups were well matched at baseline. At 12 months, the CHOICE group (n = 67) had significantly better risk factor levels than controls (n = 69) for total cholesterol (TC) (mean (SEM) 4.0 (0.1) vs 4.7 (0.1) mmol/l, p<0.001), systolic blood pressure (131.6 (1.8) vs 143.9 (2.3) mm Hg, p<0.001), body mass index (28.9 (0.7) vs 31.2 (0.7) kg/m2, p = 0.025) and physical activity (1369.1 (167.2) vs 715.1 (103.5) METS/kg/min, p = 0.001) as well as a better knowledge of risk factor targets. Also at 1 year, fewer CHOICE participants (21%) had three or more risk factors above widely recommended levels then controls (72%) (p<0.001). Conclusions: Participation in a brief CHOICE programme significantly improved the modifiable risk profiles and risk factor knowledge of ACS survivors over 12 months. CHOICE is an effective alternative for dealing with the widespread underuse of existing secondary prevention programmes. Trial registration number: ISRCTN42984084

Impact of medical consultation frequency on modifiable risk factors and medications at 12 months after acute coronary syndrome in the CHOICE randomised controlled trial

Abstract

Isolated hypertrophy of the basal ventricular septum: Characteristics of patients with and without outflow tract obstruction

AIMS Occlusive coronary artery disease (CAD) is associated with left ventricular (LV) remodeling, LV systolic dysfunction, and heart failure. The BEAUTIFUL Echo substudy aimed to evaluate the effects of heart rate reduction with ivabradine on LV size (primary end-point: change in LV end-systolic volume index [LVESVI]) and function and the cardiac biomarker N-terminal pro-brain natriuretic peptide (NT-proBNP). METHODS AND RESULTS The substudy was carried out in 86 centers participating in the BEAUTIFUL study. 2D echocardiography was performed at baseline, and after 3 and 12 months in patients with stable CAD and LV systolic dysfunction receiving ivabradine or placebo at the same time-points. All data were read and analyzed centrally. Of 525 patients completing the study, 426 had adequate echocardiographic readings (n = 220 ivabradine; n = 206 placebo). Treatment with ivabradine was associated with a decrease in the primary end-point LVESVI (change from baseline to last value, -1.48 ± 13.00 mL/m(2)) versus an increase with placebo (1.85 ± 10.54 mL/m(2)) (P=0.018). There was an increase in LV ejection fraction with ivabradine (2.00 ± 7.02%) versus no change with placebo (0.01 ± 6.20%) (P=0.009). Reduction in LVESVI was related to the degree of heart rate reduction with ivabradine. There were no differences in any other echocardiographic parameters or NT-proBNP. Change in LVESVI was related to the log change in NT-proBNP in the ivabradine group only (r = 0.18, P = 0.006). CONCLUSIONS Our observations suggest that ivabradine may reverse detrimental LV remodeling in patients with CAD and LV systolic dysfunction.

Modular prevention of heart disease following acute coronary syndrome (ACS) [ISRCTN42984084]

Objective: To determine if the improved risk factor profile at 1 year attributed to the Choice of Health Options In prevention of Cardiovascular Events (CHOICE) program was maintained at 4 years. Design: Single-blind randomized controlled trial with post-hoc 47 ± 6 months follow-up (76% complete). Setting: Australian tertiary referral hospital. Patients: Two hundred and eight acute coronary syndrome survivors. Interventions: Acute coronary syndrome survivors not accessing cardiac rehabilitation (CR) were randomized to control (n = 72) or CHOICE (n = 72) comprising the tailored risk factor reduction packaged as a clinic visit and 3 months phone support. A contemporary CR reference group were also recruited (n = 64). Blinded risk assessment occurred at baseline, 1 and 4 years. Main outcome measures: Total cholesterol, systolic blood pressure, smoking status, physical activity. Results: One year improvements in all the modifiable risk factors achieved in CHOICE were maintained at 4 years. CHOICE and control were well-matched at baseline. At 4 years, there was a trend towards lower total cholesterol in CHOICE compared with controls (mean 4.0 ± 0.1 vs. 4.2 ± 0.1 mmol/l, P = 0.05), significantly better systolic blood pressure (mean 132.2 ± 2.1 vs. 136.8 ± 2.0 mmHg, P = 0.01), physical activity scores (1200 ± 209 vs. 968 ± 196 metabolic equivalent min/week, P = 0.02) and proportion with three or more risk factors above national targets (20 vs. 42%, P = 0.02). Participants in CHOICE were at higher baseline risk than CR but at 4 years they had similar risk factor profiles. Conclusion: Participants in CHOICE maintained favorable changes in coronary risk profile at 4 years compared with control, indicating that CHOICE is an effective long-term intervention among those not accessing facility-based CR.