Estimated stroke risk, yield, and number needed to screen for atrial fibrillation detected through single time screening: a multicountry patient-level meta-analysis of 141,220 screened individuals

BACKGROUND: The precise age distribution and calculated stroke risk of screen-detected atrial fibrillation (AF) is not known. Therefore, it is not possible to determine the number needed to screen (NNS) to identify one treatable new AF case (NNS-Rx) (i.e., Class-1 oral anticoagulation [OAC] treatment recommendation) in each age stratum. If the NNS-Rx is known for each age stratum, precise cost-effectiveness and sensitivity simulations can be performed based on the age distribution of the population/region to be screened. Such calculations are required by national authorities and organisations responsible for health system budgets to determine the best age cutoffs for screening programs and decide whether programs of screening should be funded. Therefore, we aimed to determine the exact yield and calculated stroke-risk profile of screen-detected AF and NNS-Rx in 5-year age strata. METHODS AND FINDINGS: A systematic review of Medline, Pubmed, and Embase was performed (January 2007 to February 2018), and AF-SCREEN international collaboration members were contacted to identify additional studies. Twenty-four eligible studies were identified that performed a single time point screen for AF in a general ambulant population, including people \u3e /=65 years. Authors from eligible studies were invited to collaborate and share patient-level data. Statistical analysis was performed using random effects logistic regression for AF detection rate, and Poisson regression modelling for CHA2DS2-VASc scores. Nineteen studies (14 countries from a mix of low- to middle- and high-income countries) collaborated, with 141,220 participants screened and 1,539 new AF cases. Pooled yield of screening was greater in males across all age strata. The age/sex-adjusted detection rate for screen-detected AF in \u3e /=65-year-olds was 1.44% (95% CI, 1.13%-1.82%) and 0.41% (95% CI, 0.31%-0.53%) for \u3c 65-year-olds. New AF detection rate increased progressively with age from 0.34% ( \u3c 60 years) to 2.73% ( \u3e /=85 years). Neither the choice of screening methodology or device, the geographical region, nor the screening setting influenced the detection rate of AF. Mean CHA2DS2-VASc scores (n = 1,369) increased with age from 1.1 ( \u3c 60 years) to 3.9 ( \u3e /=85 years); 72% of \u3e /=65 years had \u3e /=1 additional stroke risk factor other than age/sex. All new AF \u3e /=75 years and 66% between 65 and 74 years had a Class-1 OAC recommendation. The NNS-Rx is 83 for \u3e /=65 years, 926 for 60-64 years; and 1,089 for \u3c 60 years. The main limitation of this study is there are insufficient data on sociodemographic variables of the populations and possible ascertainment biases to explain the variance in the samples. CONCLUSIONS: People with screen-detected AF are at elevated calculated stroke risk: above age 65, the majority have a Class-1 OAC recommendation for stroke prevention, and \u3e 70% have \u3e /=1 additional stroke risk factor other than age/sex. Our data, based on the largest number of screen-detected AF collected to date, show the precise relationship between yield and estimated stroke risk profile with age, and strong dependence for NNS-RX on the age distribution of the population to be screened: essential information for precise cost-effectiveness calculations

Reducing stroke risk in atrial fibrillation: Adherence to guidelines has improved, but patient persistence with anticoagulant therapy remains suboptimal.

Atrial fibrillation (AF) is a significant risk factor for avoidable stroke. Among high-risk patients with AF, stroke risk can be mitigated using oral anticoagulants (OACs), however reduction is largely contingent on physician prescription and patient persistence with OAC therapy. Over the past decade significant advances have occurred, with revisions to clinical practice guidelines relating to management of stroke risk in AF in several countries, and the introduction of non-vitamin K antagonist OACs (NOACs). This paper summarises the evolving body of research examining guideline-based clinician prescription over the past decade, and patient-level factors associated with OAC persistence. The review shows clinicians\u27 management over the past decade has increasingly reflected guideline recommendations, with an increasing proportion of high-risk patients receiving OACs, driven by an upswing in NOACs. However, a treatment gap remains, as 25–35% of high-risk patients still do not receive OAC treatment, with great variation between countries. Reduction in stroke risk directly relates to level of OAC prescription and therapy persistence. Persistence and adherence to OAC thromboprophylaxis remains an ongoing issue, with 2-year persistence as low as 50%, again with wide variation between countries and practice settings. Multiple patient-level factors contribute to poor persistence, in addition to concerns about bleeding. Considered review of individual patient\u27s factors and circumstances will assist clinicians to implement appropriate strategies to address poor persistence. This review highlights the interplay of both clinician\u27s awareness of guideline recommendations and understanding of individual patient-level factors which impact adherence and persistence, which are required to reduce the incidence of preventable stroke attributable to AF

Australian Community Pharmacists’ Experience of Implementing a Chronic Kidney Disease Risk Assessment Service

Introduction Community pharmacists are well positioned to deliver chronic kidney disease (CKD) screening services. However, little is known about the challenges faced by pharmacists during service implementation. This study aimed to explore community pharmacists’ experiences and perceived barriers of implementing a CKD risk assessment service. Methods Data collection was performed by using semistructured, open-ended interview questions. Pharmacists who had implemented a CKD screening service in Tasmania, Australia, were eligible to participate. A purposeful sampling strategy was used to select pharmacists, with variation in demographics and pharmacy location. A conventional content analysis approach was used to conduct the qualitative study. Transcripts were thematically analyzed by using the NVivo 11 software program. Initially, a list of free nodes was generated and data were coded exhaustively into relevant nodes. These nodes were then regrouped to form highly conceptualized themes. Results Five broad themes emerged from the analysis: contextual fit within community pharmacy; perceived scope of pharmacy practice; customer perception toward disease prevention; CKD – an underestimated disease; and remuneration for a beneficial service. Pharmacists found the CKD service efficient, user-friendly, and of substantial benefit to their customers. However, several pharmacists observed that their customers lacked interest in disease prevention, and had limited understanding of CKD. More importantly, pharmacists perceived the scope of pharmacy practice to depend substantially on interprofessional collaboration between pharmacists and general practitioners, and customer acknowledgment of pharmacists’ role in disease prevention. Conclusion Community pharmacists perceived the CKD service to be worth incorporating into pharmacy practice. To increase uptake, future CKD services should aim to improve customer awareness about CKD before providing risk assessment. Further research investigating strategies to enhance general practitioner involvement in pharmacist-initiated disease prevention services is also needed

Identification of patients with atrial fibrillation in UK community pharmacy: an evaluation of a new service

Background: Many patients with atrial fibrillation (AF) are asymptomatic and diagnosed via opportunistic screening. Community pharmacy has been advocated as a potential resource for opportunistic screening and lifestyle interventions.  Objective: The objective of this evaluation is to describe the outcomes from an AF service, in terms of referrals and interventions provided to patients identified as not at risk.  Method: Eligibility was assessed from pharmacy records and the completion of a short questionnaire. Once consented, patients were screened for AF and their blood pressure was measured.  Results: Of 594 patients screened, nine were identified as at risk of having AF and were referred to their GP. The service also identified 109 patients with undiagnosed hypertension, 176 patients with a Body Mass Index (BMI) > 30, 131 with an Audit-C score > 5 and 59 smokers. Pharmacists provided 413 interventions in 326 patients aimed at weight reduction (239), alcohol consumption (123) and smoking cessation (51).  Conclusion: This evaluation characterises the interventions provided to, not only those identified with the target condition - in this case AF - but also those without it. The true outcome of these additional interventions, along with appropriate follow-up, should be the focus of future studies.Impact of findings on patients or practice •Patients are willing to be screened for AF through community pharmacies•Screening can provide opportunities to identify other healthcare problems such a hypertension or poor lifestyle •Community pharmacists are able to provide brief advice to patients as a result of this opportunistic screenin

Uptake of a primary care atrial fibrillation screening program (AF-SMART): a realist evaluation of implementation in metropolitan and rural general practice

Background Screening for atrial fibrillation (AF) in people aged ≥65 years is recommended by international guidelines. The Atrial Fibrillation Screen, Management And guideline-Recommended Therapy (AF-SMART) studies of opportunistic AF screening in 16 metropolitan and rural general practices were conducted from November 2016 - June 2019. These studies trialled custom-designed eHealth tools to support all stages of AF screening in general practice. MethodsA realist evaluation of the AF-SMART studies, which aimed to explain the circumstances in which the program worked (or not) to increase the proportion of people screened for AF. The initial program theory was based on our previous research, policy documents and screening studies. To test this, we conducted 45 semi-structured interviews with general practitioners (GPs), nurses and practice managers across all participating practices, and collected observational and quantitative screening data. These data were analysed and interpreted to refine the program theory.Results GPs/nurses liked the eHealth tools, although technical problems sometimes disrupted screening. Time was the main barrier to screening for GPs/nurses, so systems need to be very efficient. Practices with leadership from a senior GP ‘screening champion’ had broader uptake, especially from the nursing team. Providing regular feedback on screening data was beneficial for quality improvement and motivation. Clear protocols for follow-up of abnormal results were required for successful nurse-led screening in a hierarchical system. Participation in the program had broader benefits of improving AF knowledge and raising the profile of cardiovascular health in the practice. Screening for a shorter, more intense period (eg during influenza vaccination) worked well for practices where sufficient staff time was allocated.ConclusionsIntroducing an AF screening program is likely to be successful in contexts where there is a senior GP ‘screening champion’, a clear protocol exists for abnormal results, and there is regular data reporting to staff. These contexts link to mechanisms around motivation, leadership, empowerment of nurses, and efficient screening systems. The contexts and mechanisms contribute to the longer-term outcomes of increasing the proportion of people screened and treated for AF, which is recommended by guidelines as a key strategy for the prevention of AF-related stroke

A stakeholder co-design approach for developing a community pharmacy service to enhance screening and management of atrial fibrillation

The authors would like to thank all participants in this research for their valuable input into the co-design process.Background: Community pharmacies provide a suitable setting to promote self-screening programs aimed at enhancing the early detection of atrial fibrillation (AF). Developing and implementing novel community pharmacy services (CPSs) is a complex and acknowledged challenge, which requires comprehensive planning and the participation of relevant stakeholders. Co-design processes are participatory research approaches that can enhance the development, evaluation and implementation of health services. The aim of this study was to co-design a pharmacist-led CPS aimed at enhancing self-monitoring/screening of AF. Methods: A 3-step co-design process was conducted using qualitative methods: (1) interviews and focus group with potential service users (n = 8) to identify key needs and concerns; (2) focus group with a mixed group of stakeholders (n = 8) to generate a preliminary model of the service; and (3) focus group with community pharmacy owners and managers (n = 4) to explore the feasibility and appropriateness of the model. Data were analysed qualitatively to identify themes and intersections between themes. The JeMa2 model to conceptualize pharmacybased health programs was used to build a theoretical model of the service. Results: Stakeholders delineated: a clear target population (i.e., individuals ≥65 years old, with hypertension, with or without previous AF or stroke); the components of the service (i.e., patient education; self-monitoring at home; results evaluation, referral and follow-up); and a set of circumstances that may influence the implementation of the service (e.g., quality of the service, competency of the pharmacist, inter-professional relationships, etc.). A number of strategies were recommended to enable implementation (e.g.,. endorsement by leading cardiovascular organizations, appropriate communication methods and channels between the pharmacy and the general medical practice settings, etc.). Conclusion: A novel and preliminary model of a CPS aimed at enhancing the management of AF was generated from this participatory process. This model can be used to inform decision making processes aimed at adopting and piloting of the service. It is expected the co-designed service has been adapted to suit existing needs of patients and current care practices, which, in turn, may increase the feasibility and acceptance of the service when it is implemented into a real setting.This work was funded by Covidien Pty Ltd. (Medtronic Australasia Pty Ltd) [UTS Project code: PRO16–0688], which is the company that has the rights to distribute the device Microlife BP A200 AFIB in Australia. Also, funding for this research has been provided by a UTS Chancellor’s postdoctoral fellowship awarded to the first author of this article (ID number: 2013001605)

Identifying postoperative atrial fibrillation in cardiac surgical patients posthospital discharge, using iPhone ECG: a study protocol

Introduction: Postoperative atrial fibrillation (AF) occurs in 30–40% of patients after cardiac surgery. Identification of recurrent postoperative AF is required to initiate evidence-based management to reduce the risk of subsequent stroke. However, as AF is oftenasymptomatic, recurrences may not be detected after discharge. This study determines feasibility and impact of a self-surveillance programme to identify recurrence of postoperative AF in the month of posthospital discharge.Methods and analysis: This is a feasibility study, using a cross-sectional study design, of self-screening for AF using a hand-held single-lead iPhone electrocardiograph device (iECG). Participants will be recruited from the cardiothoracic surgery wards of the Royal North Shore Hospital and North Shore Private Hospital, Sydney, Australia. Cardiac surgery patients admitted in sinus rhythm and experiencing a transient episode of postoperative AF will be eligible for recruitment. Participants will be taught to take daily ECGrecordings for 1 month posthospital discharge using the iECG and will be provided education regarding AF, including symptoms and health risks. The primary outcome is the feasibility of patient self-monitoring for AF recurrence using an iECG. Secondary outcomesinclude proportion of patients identified with recurrent AF; estimation of stroke risk and patient knowledge. Process outcomes and qualitative data related to acceptability of patient’s use of the iECG and sustainability of the screening programme beyond thetrial setting will also be collected.Ethics and dissemination: Primary ethics approval was received on 25 February 2014 from Northern Sydney Local Health District Human Resource Ethics Committee, and on 17 July 2014 from North Shore Private Hospital Ethics Committee. Results will bedisseminated via forums including, but not limited to, peer-reviewed publications and presentation at national and international conferences

Screening education and recognition in community pHarmacies of atrial fibrillation to prevent stroke in an ambulant population aged ?65?years (SEARCH-AF stroke prevention study): a cross-sectional study protocol

Background Atrial fibrillation (AF) is associated with a high risk of stroke and may often be asymptomatic. AF is commonly undiagnosed until patients present with sequelae, such as heart failure and stroke. Stroke secondary to AF is highly preventable with the use of appropriate thromboprophylaxis. Therefore, early identification and appropriate evidence-based management of AF could lead to subsequent stroke prevention. This study aims to determine the feasibility and impact of a community pharmacy-based screening programme focused on identifying undiagnosed AF in people aged 65?years and older. Methods and analysis This cross-sectional study of community-based screening to identify undiagnosed AF will evaluate the feasibility of screening for AF using a pulse palpation and handheld single-lead electrocardiograph (ECG) device. 10 community pharmacies will be recruited and trained to implement the screening protocol, targeting a total of 1000 participants. The primary outcome is the proportion of people newly identified with AF at the completion of the screening programme. Secondary outcomes include level of agreement between the pharmacist's and the cardiologist's interpretation of the single-lead ECG; level of agreement between irregular rhythm identified with pulse palpation and with the single-lead ECG. Process outcomes related to sustainability of the screening programme beyond the trial setting, pharmacist knowledge of AF and rate of uptake of referral to full ECG evaluation and cardiology review will also be collected

In a large primary care data set, the CHA₂DS₂-VASc score leads to an almost universal recommendation for anticoagulation treatment in those aged ≥65 years with atrial fibrillation

From 2012 to 2016, the oral anticoagulant (OAC) treatment determination for atrial fibrillation (AF) patients moved from the CHADS2 score to the CHA2DS2-VASc score. A data set collated during previous studies (2011–19) with de-identified data extracted from clinical records at a single timepoint for active adult patients (n = 285 635; 8294 with AF) attending 164 general practices in Australia was analysed. The CHA2DS2-VASc threshold (score ≥2 men/≥3 women) captured a significantly higher proportion than CHADS2≥2 (all ages: 85 vs. 68%, P < 0.0001; ≥65 years: 96 vs. 76%, P < 0.0001). The change from CHADS2 to CHA2DS2-VASc resulted in a significantly higher proportion of AF patients being recommended OAC, driven by the revised scoring for age

Atrial Fibrillation Screen, Management And Guideline Recommended Therapy (AF SMART II) in the rural primary care setting: a cross-sectional study and cost-effectiveness analysis of eHealth tools to support all stages of screening

BackgroundInternationally, most atrial fibrillation (AF) management guidelines recommend opportunistic screening for AF in people aged ≥65 years, and oral anticoagulant (OAC) treatment for those at high stroke risk (CHA₂DS₂-VA ≥2). However, gaps remain in screening and treatment.Methods and ResultsGeneral practitioners/nurses at practices in rural Australia(n=8) screened eligible patients (aged ≥65 years without AF) using a smartphone electrocardiogram during practice visits. eHealth tools included electronic prompts, guideline-based electronic decision support, and regular data reports. Clinical audit tools extracted deidentified data. Results were compared to an earlier study in metropolitan practices(n=8) and non-randomised control practices(n=69). Cost-effectiveness analysis compared population-based screening to no screening and included screening, treatment and hospitalisation costs for stroke and serious bleeding events. Patients (n=3,103, 34%) were screened (mean age 75.1±6.8 years, 47% male) and 36(1.2%) new AF cases were confirmed (mean age 77.0 years, 64% male, mean CHA₂DS₂-VA=3.2). OAC treatment rates for patients with CHA₂DS₂-VA≥2 were 82% (screen-detected) versus 74% (pre-existing AF)(p=NS), similar to metropolitan and non-randomised control practices. The incremental cost-effectiveness ratio (ICER) for population-based screening was AU$16,578/quality adjusted life year gained and AU$84,383/stroke prevented compared to no screening. National implementation would prevent 147 strokes/year. Increasing the proportion screened to 75% would prevent 177 additional strokes/year.ConclusionsAn AF screening program in rural practices, supported by eHealth tools, screened 34% of eligible patients and was cost-effective. OAC treatment rates were relatively high at baseline, trending upwards during the study. Increasing the proportion screened would prevent many more strokes with minimal ICER change. eHealth tools, including data reports, may be a valuable addition to future programs