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Williams K, Modi RN, Dymond A, Hoare S, Powell A, Burt J, Edwards D, Lund J, Johnson R, Lobban T, Lown M, Sweeting MJ, Thom H, Kaptoge S, Fusco F, Morris S, Lip G, Armstrong N, Cowie MR, Fitzmaurice DA, Freedman B, Griffin SJ, Sutton S, Hobbs FR, McManus RJ, Mant J, Safer Authorship Group T. Cluster randomised controlled trial of screening for atrial fibrillation in people aged 70 years and over to reduce stroke: protocol for the pilot study for the SAFER trial. BMJ Open 2022; 12:e065066. [PMID: 36691194 PMCID: PMC9472173 DOI: 10.1136/bmjopen-2022-065066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is a common arrhythmia associated with 30% of strokes, as well as other cardiovascular disease, dementia and death. AF meets many criteria for screening, but there is limited evidence that AF screening reduces stroke. Consequently, no countries recommend national screening programmes for AF. The Screening for Atrial Fibrillation with ECG to Reduce stroke (SAFER) trial aims to determine whether screening for AF is effective at reducing risk of stroke. The aim of the pilot study is to assess feasibility of the main trial and inform implementation of screening and trial procedures. METHODS AND ANALYSIS SAFER is planned to be a pragmatic randomised controlled trial (RCT) of over 100 000 participants aged 70 years and over, not on long-term anticoagulation therapy at baseline, with an average follow-up of 5 years. Participants are asked to record four traces every day for 3 weeks on a hand-held single-lead ECG device. Cardiologists remotely confirm episodes of AF identified by the device algorithm, and general practitioners follow-up with anticoagulation as appropriate. The pilot study is a cluster RCT in 36 UK general practices, randomised 2:1 control to intervention, recruiting approximately 12 600 participants. Pilot study outcomes include AF detection rate, anticoagulation uptake and other parameters to incorporate into sample size calculations for the main trial. Questionnaires sent to a sample of participants will assess impact of screening on psychological health. Process evaluation and qualitative studies will underpin implementation of screening during the main trial. An economic evaluation using the pilot data will confirm whether it is plausible that screening might be cost-effective. ETHICS AND DISSEMINATION The London-Central Research Ethics Committee (19/LO/1597) and Confidentiality Advisory Group (19/CAG/0226) provided ethical approval. Dissemination will be via publications, patient-friendly summaries, reports and engagement with the UK National Screening Committee. TRIAL REGISTRATION NUMBER ISRCTN72104369.
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Affiliation(s)
- Kate Williams
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rakesh Narendra Modi
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Andrew Dymond
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Hoare
- THIS (The Healthcare Improvement Studies) Institute, University of Cambridge, Cambridge, UK
| | - Alison Powell
- THIS (The Healthcare Improvement Studies) Institute, University of Cambridge, Cambridge, UK
| | - Jenni Burt
- THIS (The Healthcare Improvement Studies) Institute, University of Cambridge, Cambridge, UK
| | - Duncan Edwards
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jenny Lund
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rachel Johnson
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Mark Lown
- Primary Care Population Sciences and Medical Education, University of Southampton School, Southampton, UK
| | - Michael J Sweeting
- Department of Health Sciences, George Davies Centre, University of Leicester, Leicester, UK
| | - H Thom
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Stephen Kaptoge
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Francesco Fusco
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen Morris
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Gregory Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Natalie Armstrong
- Department of Health Sciences, George Davies Centre, University of Leicester, Leicester, UK
| | - Martin R Cowie
- Guy's & St Thomas' NHS Foundation Trust, Royal Brompton Hospital, London, UK
- Faculty of Life Sciences and Medicine, Kings College London, London, UK
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - David A Fitzmaurice
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ben Freedman
- Heart research Institute, Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Simon J Griffin
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Sutton
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jonathan Mant
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - The Safer Authorship Group
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Sehrawat O, Kashou AH, Noseworthy PA. Artificial Intelligence and Atrial Fibrillation. J Cardiovasc Electrophysiol 2022; 33:1932-1943. [PMID: 35258136 PMCID: PMC9717694 DOI: 10.1111/jce.15440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 02/03/2022] [Accepted: 03/01/2022] [Indexed: 11/30/2022]
Abstract
In the context of atrial fibrillation (AF), traditional clinical practices have thus far fallen short in several domains such as identifying patients at risk of incident AF or patients with concomitant undetected paroxysmal AF. Novel approaches leveraging artificial intelligence have the potential to provide new tools to deal with some of these old problems. In this review we focus on the roles of artificial intelligence-enabled ECG pertaining to AF, potential roles of deep learning (DL) models in the context of current knowledge gaps, as well as limitations of these models. One key area where DL models can translate to better patient outcomes is through automated ECG interpretation. Further, we overview some of the challenges facing AF screening and the harms and benefits of screening. In this context, a unique model was developed to detect underlying hidden AF from sinus rhythm and is discussed in detail with its potential uses. Knowledge gaps also remain regarding the best ways to monitor patients with embolic stroke of undetermined source (ESUS) and who would benefit most from oral anticoagulation. The AI-enabled AF model is one potential way to tackle this complex problem as it could be used to identify a subset of high-risk ESUS patients likely to benefit from empirical oral anticoagulation. Role of DL models assessing AF burden from long duration ECG data is also discussed as a way of guiding management. There is a trend towards the use of consumer-grade wristbands and watches to detect AF from photoplethysmography data. However, ECG currently remains the gold standard to detect arrythmias including AF. Lastly, role of adequate external validation of the models and clinical trials to study true performance is discussed. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ojasav Sehrawat
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anthony H Kashou
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Kahwati LC, Asher GN, Kadro ZO, Keen S, Ali R, Coker-Schwimmer E, Jonas DE. Screening for Atrial Fibrillation: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 327:368-383. [PMID: 35076660 DOI: 10.1001/jama.2021.21811] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Atrial fibrillation (AF), the most common arrhythmia, increases the risk of stroke. OBJECTIVE To review the evidence on screening for AF in adults without prior stroke to inform the US Preventive Services Task Force. DATA SOURCES PubMed, Cochrane Library, and trial registries through October 5, 2020; references, experts, and literature surveillance through October 31, 2021. STUDY SELECTION Randomized clinical trials (RCTs) of screening among asymptomatic persons without known AF or prior stroke; test accuracy studies; RCTs of anticoagulation among persons with AF; systematic reviews; and observational studies reporting harms. DATA EXTRACTION AND SYNTHESIS Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. MAIN OUTCOMES AND MEASURES Detection of undiagnosed AF, test accuracy, mortality, stroke, stroke-related morbidity, and harms. RESULTS Twenty-six studies (N = 113 784) were included. In 1 RCT (n = 28 768) of twice-daily electrocardiography (ECG) screening for 2 weeks, the likelihood of a composite end point (ischemic stroke, hemorrhagic stroke, systemic embolism, all-cause mortality, and hospitalization for bleeding) was lower in the screened group over 6.9 years (hazard ratio, 0.96 [95% CI, 0.92-1.00]; P = .045), but that study had numerous limitations. In 4 RCTs (n = 32 491), significantly more AF was detected with intermittent and continuous ECG screening compared with no screening (risk difference range, 1.0%-4.8%). Treatment with warfarin over a mean of 1.5 years in populations with clinical, mostly persistent AF was associated with fewer ischemic strokes (pooled risk ratio [RR], 0.32 [95% CI, 0.20-0.51]; 5 RCTs; n = 2415) and lower all-cause mortality (pooled RR, 0.68 [95% CI, 0.50-0.93]) compared with placebo. Treatment with direct oral anticoagulants was also associated with lower incidence of stroke (adjusted odds ratios range, 0.32-0.44) in indirect comparisons with placebo. The pooled RR for major bleeding for warfarin compared with placebo was 1.8 (95% CI, 0.85-3.7; 5 RCTs; n = 2415), and the adjusted odds ratio for major bleeding for direct oral anticoagulants compared with placebo or no treatment ranged from 1.38 to 2.21, but CIs did not exclude a null effect. CONCLUSIONS AND RELEVANCE Although screening can detect more cases of unknown AF, evidence regarding effects on health outcomes is limited. Anticoagulation was associated with lower risk of first stroke and mortality but with increased risk of major bleeding, although estimates for this harm are imprecise; no trials assessed benefits and harms of anticoagulation among screen-detected populations.
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Affiliation(s)
- Leila C Kahwati
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Gary N Asher
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Zachary O Kadro
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill
| | - Susan Keen
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Rania Ali
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Emmanuel Coker-Schwimmer
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
| | - Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus
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Jones NR, Taylor CJ, Hobbs FDR, Bowman L, Casadei B. Screening for atrial fibrillation: a call for evidence. Eur Heart J 2020; 41:1075-1085. [PMID: 31811716 PMCID: PMC7060457 DOI: 10.1093/eurheartj/ehz834] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/15/2019] [Accepted: 11/08/2019] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and prevalence is predicted to double over the next 30 years due to changing demographics and the rise in prevalence of risk factors such as hypertension and diabetes. Atrial fibrillation is associated with a five-fold increased stroke risk, but anticoagulation in eligible patients can reduce this risk by around 65%. Many people with AF currently go undetected and therefore untreated, either because they are asymptomatic or because they have paroxysmal AF. Screening has been suggested as one approach to increase AF detection rates and reduce the incidence of ischaemic stroke by earlier initiation of anticoagulation therapy. However, international taskforces currently recommend against screening, citing the cost implications and uncertainty over the benefits of a systematic screening programme compared to usual care. A number of large randomized controlled trials have commenced to determine the cost-effectiveness and clinical benefit of screening using a range of devices and across different populations. The recent AppleWatch study demonstrates how advances in technology are providing the public with self-screening devices that are increasingly affordable and accessible. Health care professionals should be aware of the implications of these emerging data for diagnostic pathways and treatment. This review provides an overview of the gaps in the current evidence and a summary of the arguments for and against screening.
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Affiliation(s)
- Nicholas R Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford OX2 6GG, UK
| | - Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford OX2 6GG, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Woodstock Road, Oxford OX2 6GG, UK
| | - Louise Bowman
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Barbara Casadei
- Radcliffe Department of Medicine, University of Oxford, Level 6 West Wing, John Radcliffe Hospital, Oxford OX3 9DU, UK
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De Bie J, Martignani C, Massaro G, Diemberger I. Performance of seven ECG interpretation programs in identifying arrhythmia and acute cardiovascular syndrome. J Electrocardiol 2019; 58:143-149. [PMID: 31884310 DOI: 10.1016/j.jelectrocard.2019.11.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/29/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND No direct comparison of current electrocardiogram (ECG) interpretation programs exists. OBJECTIVE Assess the accuracy of ECG interpretation programs in detecting abnormal rhythms and flagging for priority review records with alterations secondary to acute coronary syndrome (ACS). METHODS More than 2,000 digital ECGs from hospitals and databases in Europe, USA, and Australia, were obtained from consecutive adult and pediatric patients and converted to 10 s analog samples that were replayed on seven electrocardiographs and classified by the manufacturers' interpretation programs. We assessed ability to distinguish sinus rhythm from non-sinus rhythm, identify atrial fibrillation/flutter and other abnormal rhythms, and accuracy in flagging results for priority review. If all seven programs' interpretation statements did not agree, cases were reviewed by experienced cardiologists. RESULTS All programs could distinguish well between sinus and non-sinus rhythms and could identify atrial fibrillation/flutter or other abnormal rhythms. However, false-positive rates varied from 2.1% to 5.5% for non-sinus rhythm, from 0.7% to 4.4% for atrial fibrillation/flutter, and from 1.5% to 3.0% for other abnormal rhythms. False-negative rates varied from 12.0% to 7.5%, 9.9% to 2.7%, and 55.9% to 30.5%, respectively. Flagging of ACS varied by a factor of 2.5 between programs. Physicians flagged more ECGs for prompt review, but also showed variance of around a factor of 2. False-negative values differed between programs by a factor of 2 but was high for all (>50%). Agreement between programs and majority reviewer decisions was 46-62%. CONCLUSIONS Automatic interpretations of rhythms and ACS differ between programs. Healthcare institutions should not rely on ECG software "critical result" flags alone to decide the ACS workflow.
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Affiliation(s)
- J De Bie
- Mortara Instrument Europe s.r.l., Bologna, Italy.
| | - C Martignani
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - G Massaro
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - I Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
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Guo Y, Wang H, Zhang H, Liu T, Liang Z, Xia Y, Yan L, Xing Y, Shi H, Li S, Liu Y, Liu F, Feng M, Chen Y, Lip GYH. Mobile Photoplethysmographic Technology to Detect Atrial Fibrillation. J Am Coll Cardiol 2019; 74:2365-2375. [PMID: 31487545 DOI: 10.1016/j.jacc.2019.08.019] [Citation(s) in RCA: 247] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 08/10/2019] [Accepted: 08/19/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Low detection and nonadherence are major problems in current management approaches for patients with suspected atrial fibrillation (AF). Mobile health devices may enable earlier AF detection and improved AF management. OBJECTIVES This study sought to investigate the effectiveness of AF screening in a large population-based cohort using smart device-based photoplethysmography (PPG) technology, combined with a clinical care AF management pathway using a mobile health approach. METHODS AF screening was performed with smart devices using PPG technology, which were made available for the population ≥18 years of age across China. Monitoring for at least 14 days with a wristband (Honor Band 4) or wristwatch (Huawei Watch GT, Honor Watch, Huawei Technologies Co., Ltd., Shenzhen, China) was allowed. The patients with "possible AF" episodes using the PPG algorithm were further confirmed by health providers among the MAFA (mobile AF app) Telecare center and network hospitals, with clinical evaluation, electrocardiogram, or 24-h Holter monitoring. RESULTS There were 246,541 individuals who downloaded the PPG screening app, and 187,912 individuals used smart devices to monitor their pulse rhythm between October 26, 2018, and May 20, 2019. Among those with PPG monitoring (mean age 35 years, 86.7% male), 424 (of 187,912, 0.23%) (mean age 54 years, 87.0% male) received a "suspected AF" notification. Of those effectively followed up, 227 individuals (of 262, 87.0%) were confirmed as having AF, with the positive predictive value of PPG signals being 91.6% (95% confidential interval [CI]: 91.5% to 91.8%). Both suspected AF and identified AF markedly increased with age (p for trend <0.001), and individuals in Northeast China had the highest proportion of detected AF of 0.28% (95% CI: 0.20% to 0.39%). Of the individuals with identified AF, 216 (of 227, 95.1%) subsequently entered a program of integrated AF management using a mobile AF application; approximately 80% of high-risk patients were successfully anticoagulated. CONCLUSIONS Based on the present study, continuous home monitoring with smart device-based PPG technology could be a feasible approach for AF screening. This would help efforts at screening and detection of AF, as well as early interventions to reduce stroke and other AF-related complications. (Mobile Health [mHealth] Technology for Improved Screening, Patient Involvement and Optimizing Integrated Care in Atrial Fibrillation [MAFA II]; ChiCTR-OOC-17014138).
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Affiliation(s)
- Yutao Guo
- Chinese People's Liberation Army General Hospital, Beijing, China
| | - Hao Wang
- Chinese People's Liberation Army General Hospital, Beijing, China
| | - Hui Zhang
- Chinese People's Liberation Army General Hospital, Beijing, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Zhaoguang Liang
- The First Affiliated Hospital of Haerbing Medical University, Haerbing, China
| | - Yunlong Xia
- The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Li Yan
- Yunnan Cardiovascular Hospital, Kunmin, China
| | - Yunli Xing
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Haili Shi
- Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Shuyan Li
- The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yanxia Liu
- General Hospital of Shenyang Military, Shenyang, China
| | - Fan Liu
- The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Mei Feng
- Shanxi Da Hospital, Taiyuan, China
| | - Yundai Chen
- Chinese People's Liberation Army General Hospital, Beijing, China.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Bacchini M, Bonometti S, Del Zotti F, Lechi A, Realdon F, Fava C, Minuz P. Opportunistic Screening for Atrial Fibrillation in the Pharmacies: A Population-Based Cross-Sectional Study. High Blood Press Cardiovasc Prev 2019; 26:339-344. [PMID: 31385256 DOI: 10.1007/s40292-019-00334-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/25/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Opportunistic screening of atrial fibrillation is a valuable approach to the identification of subjects with unknown or non-symptomatic atrial fibrillation (AF) with the potential of reducing the burden of ischemic stroke in the population. AIM To evaluate the feasibility of a large-scale screening for atrial fibrillation using a blood pressure monitor (MicrolifeAFIB) endowed with a validated algorithm able to detect AF calculating the irregularity of interval times between heartbeats. METHODS In this cross-sectional study conducted in 74 pharmacies in Verona participated 3071 people aged 50 years or more. In 6 months, information about drugs, previous diagnoses of cardiovascular diseases, anthropometric and demographic data was recorded, together with the measurement of blood pressure and cardiac rhythm by using the MicrolifeAFIB device. Pharmacists also collected anthropometric and demographic data of the participants, along with information concerning their personal history of cardiovascular disease and the use of antihypertensive and antithrombotic agents. All those who were positive at the screening for atrial fibrillation were referred to their family doctor. RESULTS The screening revealed 98 subjects (3.2%) positive for AF; 44 of these reported a previous diagnosis of AF and were treated with anticoagulants (77%) or with antiplatelet agents (7%). By logistic regression analysis, age, male sex and heart failure were independently associated with positivity for AF. Association between positive test and previous stroke/TIA was found in the 54 subjects without a previous diagnosis of AF (9% had a previous stroke/TIA). CONCLUSIONS Opportunistic screening for atrial fibrillation in the pharmacies is feasible and allows to identify a number of subjects with silent, non-previously diagnosed AF, therefore is potentially useful in large-scale projects aimed at the prevention of cardiovascular morbidity and mortality.
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Affiliation(s)
| | - Samuele Bonometti
- Department of Medicine, Unit of General Medicine for the Study and Treatment of Hypertensive Disease, University of Verona, Policlinico GB Rossi, Piazzale LA Scuro, 10, 37134, Verona, Italy
| | | | - Alessandro Lechi
- Department of Medicine, Unit of General Medicine for the Study and Treatment of Hypertensive Disease, University of Verona, Policlinico GB Rossi, Piazzale LA Scuro, 10, 37134, Verona, Italy
| | | | - Cristiano Fava
- Department of Medicine, Unit of General Medicine for the Study and Treatment of Hypertensive Disease, University of Verona, Policlinico GB Rossi, Piazzale LA Scuro, 10, 37134, Verona, Italy
| | - Pietro Minuz
- Department of Medicine, Unit of General Medicine for the Study and Treatment of Hypertensive Disease, University of Verona, Policlinico GB Rossi, Piazzale LA Scuro, 10, 37134, Verona, Italy.
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Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW, Kemper AR, Kubik M, Landefeld CS, Mangione CM, Silverstein M, Simon MA, Tseng CW, Wong JB. Screening for Atrial Fibrillation With Electrocardiography: US Preventive Services Task Force Recommendation Statement. JAMA 2018; 320:478-484. [PMID: 30088016 DOI: 10.1001/jama.2018.10321] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Atrial fibrillation is the most common type of cardiac arrhythmia (irregular heartbeat), and its prevalence increases with age, affecting about 3% of men and 2% of women aged 65 to 69 years and about 10% of adults 85 years and older. Atrial fibrillation is a major risk factor for ischemic stroke, increasing risk of stroke by as much as 5-fold. Approximately 20% of patients who have a stroke associated with atrial fibrillation are first diagnosed with atrial fibrillation at the time of stroke or shortly thereafter. OBJECTIVE To issue a new US Preventive Services Task Force (USPSTF) recommendation on screening for atrial fibrillation with electrocardiography (ECG). EVIDENCE REVIEW The USPSTF reviewed the evidence on the benefits and harms of screening for atrial fibrillation with ECG in adults 65 years and older, the effectiveness of screening with ECG for detecting previously undiagnosed atrial fibrillation compared with usual care, and the benefits and harms of anticoagulant or antiplatelet therapy for the treatment of screen-detected atrial fibrillation in older adults. FINDINGS Most older adults with previously undiagnosed atrial fibrillation have a stroke risk above the threshold for anticoagulant therapy and would be eligible for treatment. Anticoagulant therapy is effective for stroke prevention in symptomatic persons with atrial fibrillation and high stroke risk. However, the USPSTF found inadequate evidence to determine whether screening with ECG and subsequent treatment in asymptomatic adults is more effective than usual care. At the same time, the harms of diagnostic follow-up and treatment prompted by abnormal ECG results are well established and include misdiagnosis and invasive testing. Given these uncertainties, it is not possible to determine the net benefit of screening with ECG. CONCLUSIONS AND RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for atrial fibrillation with ECG. (I statement).
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Affiliation(s)
| | | | - Alex H Krist
- Fairfax Family Practice Residency, Fairfax, Virginia
- Virginia Commonwealth University, Richmond
| | - Douglas K Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University, Stanford, California
| | | | | | | | | | | | | | | | | | | | | | | | - Chien-Wen Tseng
- University of Hawaii, Honolulu
- Pacific Health Research and Education Institute, Honolulu, Hawaii
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Jonas DE, Kahwati LC, Yun JDY, Middleton JC, Coker-Schwimmer M, Asher GN. Screening for Atrial Fibrillation With Electrocardiography: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018; 320:485-498. [PMID: 30088015 DOI: 10.1001/jama.2018.4190] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Atrial fibrillation is the most common arrhythmia and increases the risk of stroke. OBJECTIVE To review the evidence on screening for nonvalvular atrial fibrillation with electrocardiography (ECG) and stroke prevention treatment in asymptomatic adults 65 years or older to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, Cochrane Library, and trial registries through May 2017; references; experts; literature surveillance through June 6, 2018. STUDY SELECTION English-language randomized clinical trials (RCTs), prospective cohort studies evaluating detection rates of atrial fibrillation or harms of screening, and systematic reviews evaluating stroke prevention treatment. Eligible treatment studies compared warfarin, aspirin, or novel oral anticoagulants (NOACs) with placebo or no treatment. Studies were excluded that focused on persons with a history of cardiovascular disease. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality. When at least 3 similar studies were available, random-effects meta-analyses were conducted. MAIN OUTCOMES AND MEASURES Detection of previously undiagnosed atrial fibrillation, mortality, stroke, stroke-related morbidity, and harms. RESULTS Seventeen studies were included (n = 135 300). No studies evaluated screening compared with no screening and focused on health outcomes. Systematic screening with ECG identified more new cases of atrial fibrillation than no screening (absolute increase, from 0.6% [95% CI, 0.1%-0.9%] to 2.8% [95% CI, 0.9%-4.7%] over 12 months; 2 RCTs, n = 15 803), but a systematic approach using ECG did not detect more cases than an approach using pulse palpation (2 RCTs, n = 17 803). For potential harms, no eligible studies compared screening with no screening. Warfarin (mean, 1.5 years) was associated with a reduced risk of ischemic stroke (relative risk [RR], 0.32 [95% CI, 0.20-0.51]) and all-cause mortality (RR, 0.68 [95% CI, 0.50-0.93]) and with increased risk of bleeding (5 trials, n = 2415). Participants in treatment trials were not screen detected, and most had long-standing persistent atrial fibrillation. A network meta-analysis reported that NOACs were associated with a significantly lower risk of a composite outcome of stroke and systemic embolism (adjusted odds ratios compared with placebo or control ranged from 0.32-0.44); the risk of bleeding was increased (adjusted odds ratios, 1.4-2.2), but confidence intervals were wide and differences between groups were not statistically significant. CONCLUSIONS AND RELEVANCE Although screening with ECG can detect previously unknown cases of atrial fibrillation, it has not been shown to detect more cases than screening focused on pulse palpation. Treatments for atrial fibrillation reduce the risk of stroke and all-cause mortality and increase the risk of bleeding, but trials have not assessed whether treatment of screen-detected asymptomatic older adults results in better health outcomes than treatment after detection by usual care or after symptoms develop.
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Affiliation(s)
- Daniel E Jonas
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department of Medicine, University of North Carolina at Chapel Hill
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Leila C Kahwati
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Jonathan D Y Yun
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Manny Coker-Schwimmer
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Gary N Asher
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Department of Family Medicine, University of North Carolina at Chapel Hill
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Fay MR, Fitzmaurice DA, Freedman B. Screening of older patients for atrial fibrillation in general practice: Current evidence and its implications for future practice. Eur J Gen Pract 2018; 23:246-253. [PMID: 29034749 PMCID: PMC8816397 DOI: 10.1080/13814788.2017.1374366] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Individuals with atrial fibrillation (AF) face a fivefold increased risk of ischaemic stroke compared with those without the condition. Recent studies suggest that individuals with asymptomatic AF also face an increased risk of ischaemic stroke, but their condition is often not recognized and diagnosed until an ischaemic stroke event has occurred. Identification of individuals with undiagnosed AF at increased risk for stroke is critical in promoting optimal intervention with anticoagulants. Objectives: In this narrative review, we consider the benefits and limitations of various proposed screening strategies, whether single or multiple time-points, in addition to devices for implementation in the primary care setting. Outcomes: Opportunistic screening via pulse palpation with subsequent referral for 12-lead electrocardiogram testing has been shown to cost-effectively identify individuals with asymptomatic AF. Some handheld devices suitable for use in primary care settings are now available and may facilitate screening of large cohorts of individuals considered to be at increased risk of AF, such as those aged ≥65 years or those diagnosed with or undergoing monitoring for hypertension. Conclusions: It was determined that improved detection and diagnosis of AF, combined with appropriate anticoagulation strategies, will be crucial for improving stroke prevention and reducing its associated social and economic costs.
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Affiliation(s)
- Matthew R Fay
- a Westcliffe Practice Group and Westcliffe Cardiology Service , Shipley , West Yorkshire , UK
| | | | - Ben Freedman
- c Heart Research Institute, Charles Perkins Centre , The University of Sydney , Sydney , Australia
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11
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Nguyen T, Waits G, Soliman EZ. The Role of Resting Electrocardiogram in Screening for Primary Prevention of Cardiovascular Diseases in High-Risk Groups. CURRENT CARDIOVASCULAR RISK REPORTS 2018. [DOI: 10.1007/s12170-018-0572-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Welton NJ, McAleenan A, Thom HHZ, Davies P, Hollingworth W, Higgins JPT, Okoli G, Sterne JAC, Feder G, Eaton D, Hingorani A, Fawsitt C, Lobban T, Bryden P, Richards A, Sofat R. Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis. Health Technol Assess 2017. [DOI: 10.3310/hta21290] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BackgroundAtrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of thromboembolic events. Anticoagulation therapy to prevent AF-related stroke has been shown to be cost-effective. A national screening programme for AF may prevent AF-related events, but would involve a substantial investment of NHS resources.ObjectivesTo conduct a systematic review of the diagnostic test accuracy (DTA) of screening tests for AF, update a systematic review of comparative studies evaluating screening strategies for AF, develop an economic model to compare the cost-effectiveness of different screening strategies and review observational studies of AF screening to provide inputs to the model.DesignSystematic review, meta-analysis and cost-effectiveness analysis.SettingPrimary care.ParticipantsAdults.InterventionScreening strategies, defined by screening test, age at initial and final screens, screening interval and format of screening {systematic opportunistic screening [individuals offered screening if they consult with their general practitioner (GP)] or systematic population screening (when all eligible individuals are invited to screening)}.Main outcome measuresSensitivity, specificity and diagnostic odds ratios; the odds ratio of detecting new AF cases compared with no screening; and the mean incremental net benefit compared with no screening.Review methodsTwo reviewers screened the search results, extracted data and assessed the risk of bias. A DTA meta-analysis was perfomed, and a decision tree and Markov model was used to evaluate the cost-effectiveness of the screening strategies.ResultsDiagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age.ConclusionsA national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations.LimitationsMany inputs for the economic model relied on a single trial [the Screening for Atrial Fibrillation in the Elderly (SAFE) study] and DTA results were based on a few studies at high risk of bias/of low applicability.Future workComparative studies measuring long-term outcomes of screening strategies and DTA studies for new, emerging technologies and to replicate the results for photoplethysmography and GP interpretation of 12-lead electrocardiography in a screening population.Study registrationThis study is registered as PROSPERO CRD42014013739.FundingThe National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Nicky J Welton
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alexandra McAleenan
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Howard HZ Thom
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Philippa Davies
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Will Hollingworth
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Julian PT Higgins
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - George Okoli
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Jonathan AC Sterne
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Gene Feder
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | | | - Aroon Hingorani
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - Christopher Fawsitt
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Trudie Lobban
- Atrial Fibrillation Association, Shipston on Stour, UK
- Arrythmia Alliance, Shipston on Stour, UK
| | - Peter Bryden
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alison Richards
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Reecha Sofat
- Division of Medicine, Faculty of Medical Science, University College London, London, UK
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13
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Kaasenbrood F, Hollander M, Rutten FH, Gerhards LJ, Hoes AW, Tieleman RG. Yield of screening for atrial fibrillation in primary care with a hand-held, single-lead electrocardiogram device during influenza vaccination. Europace 2016; 18:1514-1520. [PMID: 26851813 PMCID: PMC5072135 DOI: 10.1093/europace/euv426] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 11/04/2015] [Indexed: 01/08/2023] Open
Abstract
AIMS To assess the yield of screening for atrial fibrillation (AF) with a hand-held single-lead electrocardiogram (ECG) device during influenza vaccination in primary care in the Netherlands. METHODS AND RESULTS We used the MyDiagnostick to screen for AF in persons who participated in influenza vaccination sessions of ten Dutch primary care practices. In case of suspected AF detection by the stick, the recorded 1-min ECG registrations were analysed by a cardiologist. We scrutinized electronic medical files of the general practitioners to obtain information about the cases screened. Multivariable logistic regression analysis was performed to predict the relation between patient characteristics and a new screen-detected diagnosis of AF. In total, 3269 persons were screened for AF during the influenza vaccination sessions of 10 general practitioner practices. As a result, 37 (1.1%) new cases of AF were detected. Prior transient ischeamic attack or stroke (OR 6.05; 95%CI 1.93-19.0), and age (OR 1.09 per year; 95% CI 1.05-1.14) were independent predictors for such newly screen-detected AF. Of the 37 screen-detected AF cases, 2.7% had a CHA2DS2-VASc of 0, 18.9% a score of 1, and 78.4% a score of 2 or more. The majority needed oral anticoagulant therapy. CONCLUSIONS Screening seems feasible with an easy to use single-lead, hand-held ECG device with automatic AF detection during influenza vaccination in primary care and results in a '1-day' yield of 1.1% new cases of AF. TRIAL REGISTRATION CLINICALTRIALSGOV NCT02006524.
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Affiliation(s)
- Femke Kaasenbrood
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Strat 6.131, PO Box 85500, Utrecht 3508 GA, The Netherlands
| | - Monika Hollander
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Strat 6.131, PO Box 85500, Utrecht 3508 GA, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Strat 6.131, PO Box 85500, Utrecht 3508 GA, The Netherlands
| | - Leo J Gerhards
- Department of Cardiology, Martini Hospital Groningen, Van Swietenplein 1, Groningen 9728 NT, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Strat 6.131, PO Box 85500, Utrecht 3508 GA, The Netherlands
| | - Robert G Tieleman
- Department of Cardiology, Martini Hospital Groningen, Van Swietenplein 1, Groningen 9728 NT, The Netherlands.,Department of Cardiology, University Medical Center Groningen, Hanzeplein 1, Groningen 9713 GZ, The Netherlands
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15
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Research into practice: management of atrial fibrillation in general practice. Br J Gen Pract 2015; 64:540-2. [PMID: 25267044 DOI: 10.3399/bjgp14x682057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Hobbs FR, Taylor CJ, Jan Geersing G, Rutten FH, Brouwer JR. European Primary Care Cardiovascular Society (EPCCS) consensus guidance on stroke prevention in atrial fibrillation (SPAF) in primary care. Eur J Prev Cardiol 2015; 23:460-73. [PMID: 25701017 PMCID: PMC4766963 DOI: 10.1177/2047487315571890] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 01/19/2015] [Indexed: 01/25/2023]
Abstract
Background Atrial fibrillation affects 1–2% of the general population and 10% of those over 75, and is responsible for around a quarter of all strokes. These strokes are largely preventable by the use of anticoagulation therapy, although many eligible patients are not treated. Recent large clinical trials have added to the evidence base on stroke prevention and international clinical guidelines have been updated. Design Consensus practical recommendations from primary care physicians with an interest in vascular disease and vascular specialists. Methods A focussed all-day meeting, with presentation of summary evidence under each section of this guidance and review of European guidelines on stroke prevention in atrial fibrillation, was used to generate a draft document, which then underwent three cycles of revision and debate before all panel members agreed with the consensus statements. Results Six areas were identified that included how to identify patients with atrial fibrillation, how to determine their stroke risk and whether to recommend modification of this risk, and what management options are available, with practical recommendations on maximising benefit and minimising risk if anticoagulation is recommended and the reasons why antiplatelet therapy is no longer recommended. The summary evidence is presented for each area and simple summary recommendations are highlighted, with areas of remaining uncertainty listed. Conclusions Atrial fibrillation-related stroke is a major public health priority for most health systems. This practical guidance can assist generalist community physicians to translate the large evidence base for this cause of preventable stroke and implement this at a local level.
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Affiliation(s)
- Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Clare J Taylor
- Department of Primary Care Clinical Sciences, University of Birmingham, UK
| | - Geert Jan Geersing
- Julius Center for Health Sciences and Primary Care, University of Utrecht, the Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University of Utrecht, the Netherlands
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