Stroke prevention in atrial fibrillation through screening and lifestyle interventions

Abstract

The stroke and health burden associated with atrial fibrillation (AF) is significant and likely to escalate. This burden could be markedly reduced through early identification of AF, and through appropriate management. This thesis aimed to explore the feasibility of community based screening to identify AF, and the effect of risk factor reduction once AF is identified. Firstly, the prevalence of undiagnosed AF identified in community screening was determined through a systematic literature review. Subsequently, a simple AF screening program using innovative smartphone ECG technology was performed in ten community pharmacies in Sydney, Australia. Feasibility and cost effectiveness was evaluated, including qualitative analysis of barriers and enablers to implementation. Additionally, the effect of risk factor management programs was determined by performing a systematic literature review. Finally, the feasibility of a simple brief risk factor management program for people with AF was evaluated. Community screening for AF ≥65 years identifies 1.4% with previously unknown AF, of whom the majority are asymptomatic and at sufficient stroke risk to be eligible for oral anticoagulation for stroke prevention. Screening within community pharmacies, using a handheld ECG, is feasible and cost-effective for stroke prevention, and is warranted as an additional measure to current practice, however a sustainable source of funding is required. Engagement with third party payers is necessary to determine an appropriate funding model. Further research is required to identify a way in which screening can be optimally incorporated into pharmacy workflow. Once AF is identified, lifestyle interventions to address modifiable risk factors in people with AF show great potential for reducing the burden of AF and associated morbidities. Robust randomised controlled trials of novel approaches are needed to identify a suitable and sustainable model of care for delivery of lifestyle interventions