Screening For Atrial Fibrillation In The Community Using A Novel ECG Recorder

Subclinical Atrial Fibrillation Screening in Dialytic Chronic Kidney Disease Patients Using Portable Device

BACKGROUND

Cardiovascular morbidity and mortality rates are higher in hemodialysis (HD) patients, with an increased prevalence of arrhythmias. Atrial fibrillation (AF) is an independent risk factor for mortality and thromboembolic events in dialysis patients. For a better understanding and management of AF in these patients, it is important to know its prevalence. The use of a portable device would be pioneering for this group of patients.

OBJECTIVE

To screen HD patients for AF using a portable gadget and evaluate the device's diagnostic performance.

METHODS

HD patients at a tertiary hospital underwent AF screening during HD sessions using MyDiagnostick® (Applied Biomedical Systems). Multiple data were collected to evaluate potential associations. Statistical significance was defined as p < 0.05.

RESULTS

388 patients were evaluated (female, 40.7%; mean age of 56.8 years old, SD ± 14.7; and HD time of 27 months, 10-57). Screening was positive in 16 (4.1%) patients. AF was confirmed by electrocardiogram in 7 (1.8%) patients. Male sex (p = 0.019), older age (p = 0.007), altered baseline electrocardiogram (p < 0.001), increased serum potassium (p = 0.021), reduced systolic blood pressure at the beginning of dialysis (p = 0.007), and stable angina (0.011) were associated with positive screening for AF. The device presented a 91.74% specificity (95% CI, 86.65% to 96.91%) and 100% sensitivity (95% CI, 100% to 100%), with a negative predictive value of 100% (95% CI, 100% to 100%) for AF screening.

CONCLUSION

The use of this device proved to be practical, with high sensitivity and excellent negative predictive value. Subclinical AF has a high prevalence and may be underestimated in this population.

Screening of unknown atrial fibrillation through handheld device in the elderly

OBJECTIVE

To estimate the prevalence of unknown atrial fibrillation (AF) in the elderly population of the Veneto Region, Italy.

METHODS

1820 patients aged ≥ 65 years with no history of AF and not anticoagulated were enrolled in primary-care settings. They underwent an opportunistic electrocardiogram screening with a handheld device (MyDiagnostick) designed to specifically detect AF. The electrocardiogram recordings were reviewed by the researchers, who confirmed the presence of AF.

RESULTS

The device detected an arrhythmia in 143 patients, which was confirmed as AF in 101/143 (70.6%), with an overall prevalence of AF of 5.5% (101/1820). Prevalence of unknown AF resulted in 3.6% in patients aged 65-74 years, and 7.5% in patients age 75 or older, and increased according to CHA₂DS₂-VASc score: 3.5% in patients with a score of 1 or 2, 5.6% in patients with a score of 3, 7.0% in patients with a score of 4, and 7.2% in patients with a score ≥ 5. The detection rate was significantly higher in patients with mild symptoms compared to asymptomatic counterparts (24.1% vs. 4.0%, P < 0.0001). At multivariate analysis, congestive heart failure and age ≥ 75 years-old were independent predictors for screen-detected AF.

CONCLUSIONS

An opportunistic screening with handheld device revealed an unexpectedly high prevalence of unknown AF in elderly patients with mild symptoms. Prevalence increased with age and CHA₂DS₂-VASc score.

Lead-I ECG for detecting atrial fibrillation in patients with an irregular pulse using single time point testing: a systematic review and economic evaluation

BACKGROUND

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia and is associated with an increased risk of stroke and congestive heart failure. Lead-I electrocardiogram (ECG) devices are handheld instruments that can be used to detect AF at a single time point in people who present with relevant signs or symptoms.

OBJECTIVE

To assess the diagnostic test accuracy, clinical impact and cost-effectiveness of using single time point lead-I ECG devices for the detection of AF in people presenting to primary care with relevant signs or symptoms, and who have an irregular pulse compared with using manual pulse palpation (MPP) followed by a 12-lead ECG in primary or secondary care.

DATA SOURCES

MEDLINE, MEDLINE Epub Ahead of Print and MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, PubMed, Cochrane Databases of Systematic Reviews, Cochrane Central Database of Controlled Trials, Database of Abstracts of Reviews of Effects and the Health Technology Assessment Database.

METHODS

The systematic review methods followed published guidance. Two reviewers screened the search results (database inception to April 2018), extracted data and assessed the quality of the included studies. Summary estimates of diagnostic accuracy were calculated using bivariate models. An economic model consisting of a decision tree and two cohort Markov models was developed to evaluate the cost-effectiveness of lead-I ECG devices.

RESULTS

No studies were identified that evaluated the use of lead-I ECG devices for patients with signs or symptoms of AF. Therefore, the diagnostic accuracy and clinical impact results presented are derived from an asymptomatic population (used as a proxy for people with signs or symptoms of AF). The summary sensitivity of lead-I ECG devices was 93.9% [95% confidence interval (CI) 86.2% to 97.4%] and summary specificity was 96.5% (95% CI 90.4% to 98.8%). One study reported limited clinical outcome data. Acceptability of lead-I ECG devices was reported in four studies, with generally positive views. The de novo economic model yielded incremental cost-effectiveness ratios (ICERs) per quality-adjusted life-year (QALY) gained. The results of the pairwise analysis show that all lead-I ECG devices generated ICERs per QALY gained below the £20,000-30,000 threshold. Kardia Mobile (AliveCor Ltd, Mountain View, CA, USA) is the most cost-effective option in a full incremental analysis.

LIMITATIONS

No published data evaluating the diagnostic accuracy, clinical impact or cost-effectiveness of lead-I ECG devices for the population of interest are available.

CONCLUSIONS

Single time point lead-I ECG devices for the detection of AF in people with signs or symptoms of AF and an irregular pulse appear to be a cost-effective use of NHS resources compared with MPP followed by a 12-lead ECG in primary or secondary care, given the assumptions used in the base-case model.

FUTURE WORK

Studies assessing how the use of lead-I ECG devices in this population affects the number of people diagnosed with AF when compared with current practice would be useful.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018090375.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Lead-I ECG for detecting atrial fibrillation in patients attending primary care with an irregular pulse using single-time point testing: A systematic review and economic evaluation

BACKGROUND

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia and is associated with increased risk of stroke and congestive heart failure. Lead-I electrocardiogram (ECG) devices are handheld instruments that can detect AF at a single-time point.

PURPOSE

To assess the diagnostic test accuracy, clinical impact and cost effectiveness of single-time point lead-I ECG devices compared with manual pulse palpation (MPP) followed by a 12-lead ECG for the detection of AF in symptomatic primary care patients with an irregular pulse.

METHODS

Electronic databases (MEDLINE, MEDLINE Epub Ahead of Print and MEDLINE In-Process, EMBASE, PubMed and Cochrane Databases of Systematic Reviews, Cochrane Central Database of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database) were searched to March 2018. Two reviewers screened the search results, extracted data and assessed study quality. Summary estimates of diagnostic accuracy were calculated using bivariate models. Cost-effectiveness was evaluated using an economic model consisting of a decision tree and two cohort Markov models.

RESULTS

Diagnostic accuracy The diagnostic accuracy (13 publications reporting on nine studies) and clinical impact (24 publications reporting on 19 studies) results are derived from an asymptomatic population (used as a proxy for people with signs or symptoms of AF). The summary sensitivity of lead-I ECG devices was 93.9% (95% confidence interval [CI]: 86.2% to 97.4%) and summary specificity was 96.5% (95% CI: 90.4% to 98.8%). Cost effectiveness The de novo economic model yielded incremental cost effectiveness ratios (ICERs) per quality adjusted life year (QALY) gained. The results of the pairwise analysis show that all lead-I ECG devices generate ICERs per QALY gained below the £20,000-£30,000 threshold. Kardia Mobile is the most cost effective option in a full incremental analysis. Lead-I ECG tests may identify more AF cases than the standard diagnostic pathway. This comes at a higher cost but with greater patient benefit in terms of mortality and quality of life.

LIMITATIONS

No published data evaluating the diagnostic accuracy, clinical impact or cost effectiveness of lead-I ECG devices for the target population are available.

CONCLUSIONS

The use of single-time point lead-I ECG devices in primary care for the detection of AF in people with signs or symptoms of AF and an irregular pulse appears to be a cost effective use of NHS resources compared with MPP followed by a 12-lead ECG, given the assumptions used in the base case model.

REGISTRATION

The protocol for this review is registered on PROSPERO as CRD42018090375.

Atrial fibrillation detection using single lead portable electrocardiographic monitoring: a systematic review and meta-analysis

OBJECTIVES

Recent technology advances have allowed for heart rhythm monitoring using single-lead ECG monitoring devices, which can be used for early diagnosis of atrial fibrillation (AF). We sought to investigate the AF detection rate using portable ECG devices compared with Holter monitoring.

SETTING, PARTICIPANTS AND OUTCOME MEASURES

We searched the Medline, Embase and Scopus databases (conducted on 8 May 2017) using search terms related to AF screening and included studies with adults aged >18 years using portable ECG devices or Holter monitoring for AF detection. We excluded studies using implantable loop recorders and pacemakers. Using a random-effects model we calculated the overall AF detection rate. Meta-regression analysis was performed to explore potential sources for heterogeneity. Quality of reporting was assessed using the tool developed by Downs and Black.

RESULTS

Portable ECG monitoring was used in 18 studies (n=117 436) and Holter monitoring was used in 36 studies (n=8498). The AF detection rate using portable ECG monitoring was 1.7% (95% CI 1.4 to 2.1), with significant heterogeneity between studies (p<0.001). There was a moderate linear relationship between total monitoring time and AF detection rate (r=0.65, p=0.003), and meta-regression identified total monitoring time (p=0.005) and body mass index (p=0.01) as potential contributors to heterogeneity. The detection rate (4.8%, 95% CI 3.6% to 6.0%) in eight studies (n=10 199), which performed multiple ECG recordings was comparable to that with 24 hours Holter (4.6%, 95% CI 3.5% to 5.7%). Intermittent recordings for 19 min total produced similar AF detection to 24 hours Holter monitoring.

CONCLUSION

Portable ECG devices may offer an efficient screening option for AF compared with 24 hours Holter monitoring.

PROSPERO REGISTRATION NUMBER

CRD42017061021.

The involvement of pharmacies in the screening of undiagnosed atrial fibrillation

Early identification of atrial fibrillation (AF) is now a priority in cardiovascular prevention because AF is common although often asymptomatic, and is associated with poor outcomes that are highly preventable with appropriate medical treatment. In Italy, AF prevalence among subjects aged ≥65 years ranges from 5 to 6% in observational studies based on the diagnosis recorded by general practitioners to 10-11% in studies where ECG screening is routinely offered. It is thus evident that a large number of subjects are not detected by conventional approach, and new strategies are required to increase early detection of AF. In particular, the changing position of pharmacies in the health system should be considered. Because of its small geographical size, insular nature and captive population, the Isle of Elba represents an ideal setting to test new strategies for stroke reduction. The Elba-FA project was thus designed to determine the feasibility and impact of the combined involvement of pharmacies and general practices to screen undiagnosed AF, with the ultimate aim of reducing the burden of stroke and arterial thromboembolism. The findings obtained with this approach might have broad implications for cardiovascular prevention at the general population level in Italy.