Yield of screening for atrial fibrillation in primary care with a hand-held, single-lead electrocardiogram device during influenza vaccination

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 clinicaltrials.gov NCT02006524

Incidence, risk, and case fatality of first ever stroke in the elderly population. The Rotterdam Study

OBJECTIVE: To estimate the incidence, survival, and lifetime risk of stroke in the elderly population. METHODS: The authors conducted a study in 7,721 participants from the population based Rotterdam Study who were free from stroke at baseline (1990-1993) and were followed up for stroke until 1 January 1999. Age and sex specific incidence, case fatality rates, and lifetime risks of stroke were calculated. RESULTS: Mean follow up was 6.0 years and 432 strokes occurred. The incidence rate of stroke per 1,000 person years increased with age and ranged from 1.7 (95% CI 0.4 to 6.6) in men aged 55 to 59 years to 69.8 (95% CI 22.5 to 216.6) in men aged 95 years or over. Corresponding figures for women were 1.2 (95% CI 0.3 to 4.7) and 33.1 (95% CI 17.8 to 61.6). Men and women had similar absolute lifetime risks of stroke (21% for those aged 55 years). The survival after stroke did not differ according to sex. CONCLUSIONS: Stroke incidence increases with age, also in the very old. Although the incidence rate is higher in men than in women over the entire age range, the lifetime risks were similar for both sexes

Incidence of atrial fibrillation, ischaemic heart disease and heart failure in patients with diabetes

BACKGROUND: Diabetes has strongly been linked to atrial fibrillation, ischaemic heart disease and heart failure. The epidemiology of these cardiovascular diseases is changing, however, due to changes in prevalence of obesity-related conditions and preventive measures. Recent population studies on incidence of atrial fibrillation, ischaemic heart disease and heart failure in patients with diabetes are needed. METHODS: A dynamic longitudinal cohort study was performed using primary care databases of the Julius General Practitioners’ Network. Diabetes status was determined at baseline (1 January 2014 or upon entering the cohort) and participants were followed-up for atrial fibrillation, ischaemic heart disease and heart failure until 1 February 2019. Age and sex-specific incidence and incidence rate ratios were calculated. RESULTS: Mean follow-up was 4.2 years, 12,168 patients were included in the diabetes group, and 130,143 individuals in the background group. Incidence rate ratios, adjusted for age and sex, were 1.17 (95% confidence interval 1.06–1.30) for atrial fibrillation, 1.66 (1.55–1.83) for ischaemic heart disease, and 2.36 (2.10–2.64) for heart failure. Overall, incidence rate ratios were highest in the younger age categories, converging thereafter. CONCLUSION: There is a clear association between diabetes and incidence of the major chronic progressive heart diseases, notably with heart failure with a more than twice increased risk. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12933-021-01313-7

Opportunistic screening versus usual care for diagnosing atrial fibrillation in general practice:a cluster randomised controlled trial

BackgroundAtrial fibrillation [AF] increases the risk of stroke, heart failure, and all-cause mortality. AF may be asymptomatic and therefore remain undiagnosed. Devices such as single-lead electrocardiographs [ECGs] may help GPs to diagnose AF.AimTo investigate the yield of opportunistic screening for AF in usual primary care using a single-lead ECG device.Design and settingA clustered, randomised controlled trial among patients aged &gt;= 65 years with no recorded AF status in the Netherlands from October 2014 to March 2016.MethodFifteen intervention general practices used a single-lead ECG device at their discretion and 16 control practices offered usual care. The follow-up period was 1 year, and the primary outcome was the proportion of newly diagnosed cases of AF.ResultsIn total. 17 107 older people with no recorded AF status were eligible to participate in the study. In the intervention arm. 10.7% of eligible patients [n = 919] were screened over the duration of the study year. The rate of newly diagnosed AF was similar in the intervention and control practices [1.43% versus 1.37%, P= 0.73]. Screened patients were more likely to have comorbidities, such as hypertension [60.0% versus 48.7%], type 2 diabetes [24.3% versus 18.6%], and chronic obstructive pulmonary disease [11.3% versus 7.4%], than eligible patients not screened in the intervention arm. Among patients with newly diagnosed AF in intervention practices. 27% were detected by screening, 23% by usual primary care. and 50% by a medical specialist or after stroke/transient ischaemic attack.ConclusionOpportunistic screening with a single-lead ECG at the discretion of the GP did not result in a higher yield of newly detected cases of AF in patients aged &gt;= 65 years in the community than usual care. For higher participation rates in future studies, more rigorous screening methods are needed.</p

The new Primary Care and Risk Factor Management (PCRFM) nucleus of the European Association of Preventive Cardiology: A call for action.

In recent decades, cardiovascular mortality has reduced significantly. Among others, improved treatment options for cardiovascular disease (CVD) and a reduction of smoking since the 1960s have contributed to this decline.1 In many countries, smoking in public areas is prohibited. However, western dietary habits, including foods high in sugar, salt and fat, and lack of exercise are still persistent, leading to obesity, diabetes and hypertension. Yet, despite numerous guidelines on prevention and treatment of CVD with medication and lifestyle management, the incidence of CVD is still increasing in many countries, fuelled by rising obesity levels, sedentary lifestyles and increased longevity.2 In particular in the southern hemisphere CVD is on the increase, with high rates of obesity, diabetes and hypertension.3 Demographics are changing in low and middle income countries, fuelling the rise of chronic diseases and a persistent burden of infectious diseases overwhelming the limited health care resources.4 In western countries survival after CVD events has successfully improved; however, at the price of more patients living with chronic CVDs.5 These developments will lead to an increased demand on healthcare services now and in the years ahead for both the prevention and the management of CVD. The organisation and continuity of care through the various layers of the different national healthcare systems is challenging and calls for close collaboration between hospital specialists, general practitioners (GPs) and other primary care workers in the battle against CVD. GPs are key in identifying patients at risk of CVD and providing individualised, risk stratified preventive careThe author(s) received no financial support for the research, authorship, and/or publication of this articl

Carotid plaques increase the risk of stroke and subtypes of cerebral infarction in asymptomatic elderly: the Rotterdam study

BACKGROUND: Few studies have quantified the relation between carotid plaques and stroke in asymptomatic patients, and limited data exist on the importance of location of plaques or the association with subtypes of cerebral infarction. We investigated the relationship between carotid plaques, measured at different locations, and risk of stroke and subtypes of cerebral infarction in a population-based study. Methods and Results- The study was based on the Rotterdam Study and included 4217 neurologically asymptomatic subjects aged 55 years or older. Presence of carotid plaques at 6 locations in the carotid arteries was assessed at baseline. Severity was categorized according to the number of affected sites. After a mean follow-up of 5.2 years, 160 strokes had occurred. Data were analyzed using Cox proportional hazards regression. Plaques increased the risk of stroke and cerebral infarction approximately 1.5-fold, irrespective of plaque location. Severe carotid plaques increased the risk of nonlacunar infarction in anterior (RR 3.2 [95% CI, 1.1 to 9.7]) but not in posterior circulation (RR 0.6 [95% CI, 0.1 to 4.9]). A >10-fold increased risk of lacunar infarction was found in subjects with severe plaques (RR 10.8 [95% CI, 1.7 to 69.7]). No clear difference in risk estimates was seen between ipsilateral and contralateral infarction. CONCLUSIONS: Carotid plaques increase the risk of stroke and cerebral infarction, irrespective of their location. Plaques increase the risk of infarctions in the anterior but not in the posterior circulation. It is likely that carotid plaques in neurologically asymptomatic subjects are both markers of generalized atherosclerosis and sources of thromboemboli

Is carotid intima-media thickness useful in cardiovascular disease risk assessment? The Rotterdam Study

BACKGROUND AND PURPOSE: We determined the contribution of common carotid intima-media thickness (IMT) in the prediction of future coronary heart disease and cerebrovascular disease when added to established risk factors. METHODS: We used data from a nested case-control study comprising 374 subjects with either an incident stroke or a myocardial infarction and 1496 controls.

Improving early diagnosis of cardiovascular disease in patients with type 2 diabetes and COPD:Protocol of the RED-CVD cluster randomised diagnostic trial

Introduction: The early stages of chronic progressive cardiovascular disease (CVD) generally cause non-specific symptoms that patients often do not spontaneously mention to their general practitioner, and are therefore easily missed. A proactive diagnostic strategy has the potential to uncover these frequently missed early stages, creating an opportunity for earlier intervention. This is of particular importance for chronic progressive CVDs with evidence-based therapies known to improve prognosis, such as ischaemic heart disease, atrial fibrillation and heart failure. Patients with type 2 diabetes or chronic obstructive pulmonary disease (COPD) are at particularly high risk of developing CVD. In the current study, we will demonstrate the feasibility and effectiveness of screening these high-risk patients with our early diagnosis strategy, using tools that are readily available in primary care, such as symptom questionnaires (to be filled out by the patients themselves), natriuretic peptide measurement and electrocardiography. Methods and analysis: The Reviving the Early Diagnosis-CVD trial is a multicentre, cluster randomised diagnostic trial performed in primary care practices across the Netherlands. We aim to include 1300 (2×650) patients who participate in a primary care disease management programme for COPD or type 2 diabetes. Practices will be randomised to the intervention arm (performing the early diagnosis strategy during the routine visits that are part of the disease management programmes) or the control arm (care as usual). The main outcome is the number of newly detected cases with CVDs in both arms, and the subsequent therapies they received. Secondary endpoints include quality of life, cost-effectiveness and the added diagnostic value of family and reproductive history questionnaires and three (novel) biomarkers (high-sensitive troponin-I, growth differentiation factor-15 and suppressor of tumourigenicity 2). Finally newly initiated treatments will be compared in both groups. Ethics and dissemination: The protocol was approved by the Medical Ethical Committee of the University Medical Center Utrecht, the Netherlands. Results are expected in 2022 and will be disseminated through international peer-reviewed publications. Trial registration number NTR7360

Health economic evaluation of nation-wide screening programmes for atrial fibrillation in the Netherlands

AIMS: Screening for atrial fibrillation (AF) is recommended by the European Society of Cardiology guideline to prevent strokes. Cost-effectiveness analyses of different screening programs for AF are difficult to compare, because of varying settings and models used. We compared the impact and cost-effectiveness of various AF screening programs in the Netherlands.METHODS AND RESULTS: The base case economic analysis was conducted from the societal perspective. Health effects and costs were analysed using a Markov model. The main model inputs were derived from the ARISTOTLE, RE-LY and ROCKET AF trial combined with Dutch observational data. Univariate, probabilistic sensitivity and various scenario analyses were performed. The maximum number of newly detected AF patients in The Netherlands ranged from 4554 to 39 270, depending on the screening strategy used. Adequate treatment with anticoagulation would result in a maximum of more than 3000 strokes prevented using single time point AF screening. Compared with no screening, screening 100 000 persons provided a gain in QALYs ranging from 984 to 8727, and a mean cost difference ranging from -6650 000€ to 898 000€, depending on the screening strategy used. Probabilistic sensitivity analysis (PSA) demonstrated a 100% likelihood that screening all patients ≥ 75 years visiting the Geriatric outpatient clinic was cost-saving. Four out of six strategies were cost-saving in ≥ 74% of the PSA simulations. Out of these, opportunistic screening of all patients ≥ 65 years visiting the GPs office had the highest impact on strokes prevented.CONCLUSION: Most single-time point AF screening strategies are cost-saving and have an important impact on stroke prevention.</p

Health economic evaluation of nation-wide screening programmes for atrial fibrillation in the Netherlands

AIMS: Screening for atrial fibrillation (AF) is recommended by the European Society of Cardiology guideline to prevent strokes. Cost-effectiveness analyses of different screening programs for AF are difficult to compare, because of varying settings and models used. We compared the impact and cost-effectiveness of various AF screening programs in the Netherlands.METHODS AND RESULTS: The base case economic analysis was conducted from the societal perspective. Health effects and costs were analysed using a Markov model. The main model inputs were derived from the ARISTOTLE, RE-LY and ROCKET AF trial combined with Dutch observational data. Univariate, probabilistic sensitivity and various scenario analyses were performed. The maximum number of newly detected AF patients in The Netherlands ranged from 4554 to 39 270, depending on the screening strategy used. Adequate treatment with anticoagulation would result in a maximum of more than 3000 strokes prevented using single time point AF screening. Compared with no screening, screening 100 000 persons provided a gain in QALYs ranging from 984 to 8727, and a mean cost difference ranging from -6650 000€ to 898 000€, depending on the screening strategy used. Probabilistic sensitivity analysis (PSA) demonstrated a 100% likelihood that screening all patients ≥ 75 years visiting the Geriatric outpatient clinic was cost-saving. Four out of six strategies were cost-saving in ≥ 74% of the PSA simulations. Out of these, opportunistic screening of all patients ≥ 65 years visiting the GPs office had the highest impact on strokes prevented.CONCLUSION: Most single-time point AF screening strategies are cost-saving and have an important impact on stroke prevention.</p