Atrial Fibrillation In Primary Care Research Articles

How can the detection of AF be improved? Insights from patient journeys and primary care clinicians

Abstract Background Atrial fibrillation (AF) is underdiagnosed and it is estimated that a third of people with AF remain undiagnosed. AF is complex to detect because it can be intermittent and some patients are asymptomatic. When symptoms are present they can be non-specific. In the absence of a screening programme to detect AF it is important to identify ways to improve its detection of AF in order to reduce the risk of AF-related stroke. Purpose We conducted a qualitative study in primary care to explore the patient path to diagnosis of AF and identify ways to improve detection Methods We recruited patients with a recent diagnosis of AF (< 6 months) and interviewed them to understand their path to diagnosis. We interviewed GPs and practice nurses to explore their experience of detecting AF in primary care. The interviews were audio-recorded and transcribed, and the data were analysed using framework analysis. Results Thirty patients and ten primary care clinicians were interviewed. The presence and nature of symptoms experienced by patients and how they interpreted these were significant in the pathways to diagnosis. Patients with acute symptoms presented to A &E and had a quick diagnosis while asymptomatic patients were diagnosed incidentally. Patients with non-specific symptoms generally did not perceive the symptoms as serious, and many delayed seeing a healthcare professional. Their experiences in primary care aligned with findings from interviews with primary care clinicians, who acknowledged AF may not necessarily be the initial suspicion when a patient presents with certain non-specific symptoms. Primary care clinicians described narratives of good practice in the form of opportunistic pulse palpation, as well as challenges of detecting AF in primary care. These included lack of access to 24-hour ambulatory ECG in primary care and limited opportunities to detect AF due to healthcare assistants taking on more responsibilities. Conclusions A number of opportunities to improve the detection of AF can be drawn from these findings. Public education about AF, its signs and symptoms would increase patient knowledge and presentation to healthcare professionals. Standardizing good practice of opportunistic pulse palpation in primary care and training healthcare assistants to perform this is also indicated. Access to 24-hour ambulatory ECG in primary care will reduce delays in diagnosis. Further research on which patients are likely to have undiagnosed AF will facilitate detection in primary care.

Screening and detection of atrial fibrillation in primary care: current practice and future perspectives.

Atrial fibrillation (AF) is a common arrhythmia associated with an increased risk of stroke, which can be effectively reduced by prophylaxis initiation and integrated care to reduce cardiovascular risk and AF-related complications. Screening for AF has the potential to improve long-term clinical outcomes through timely AF detection in asymptomatic patients. With the central role of primary care in most European healthcare systems in terms of disease detection, treatment, as well as record keeping, primary care is ideally situated as a setting for AF screening efforts. In this review, we provide an overview of evidence relating to AF screening in primary care. We discuss current practices of AF detection and screening, evidence from AF screening trials conducted in primary care settings, stakeholder views on barriers and facilitators for AF screening in primary care, and important aspects that will likely shape routine primary care AF detection as well as AF screening efforts. Finally, we present a potential outline for a primary care-centred AF screening trial coupled to integrated AF care that could further improve the benefit of AF screening.

Health Professionals’ Preferences of Screening for Atrial Fibrillation in Primary Care—A Discrete Choice Analysis

Health Professionals’ Preferences of Screening for Atrial Fibrillation in Primary Care—A Discrete Choice Analysis

Diagnosis and management of atrial fibrillation in primary care: a case study

This critically reflective case study will look at a 65-year-old male presenting with dyspnoea and an incidental diagnosis of atrial fibrillation (AF) in a primary care setting. The article critically analyses the diagnosis and management of the patient, considers potential differential diagnoses, current guidelines, and areas for service improvement. The author, a trainee advanced clinical practitioner (ACP) prescriber with a paramedic background, discusses the complexity of managing AF and the need for collaboration with a general practitioner. AF is a common cardiac arrhythmia associated with a significantly increased risk of stroke. The primary focus of AF management is stroke prevention. This article delves into the pathophysiology of AF, discussing its various causes and classifications, emphasising the role of left atrial appendage (LAA) in stroke risk. The limitations of AF screening methods, especially for paroxysmal AF, are also discussed. Recent advancements in opportunistic screening, including the use of artificial intelligence (AI) and smartwatches, show promise but require further research and validation. This article explores stroke risk assessment tools like CHA2DS2VASc and ATRIA, bleeding risk assessment using HAS-BLED and ORBIT scores, as well as rhythm control in newly diagnosed AF cases. Finally, the importance of lifestyle modifications and regular patient follow-up are underscored. AF diagnosis and management are multifaceted, involving stroke prevention, rate or rhythm control, and lifestyle modifications. Technological advancements hold promise in improving early AF detection. Collaborative efforts between healthcare providers and adherence to current guidelines are crucial in achieving optimal patient outcomes, while future practice may benefit from enhanced diagnostic screening and treatment options as further research unfolds.

Atrial fibrillation and electronic healthcare records in UK Biobank: Relevance of ascertainment in primary and secondary care for risk factor associations and patient outcomes

Abstract Background Electronic health data have played a pivotal role in the development and success of large-scale biobanks, and have enabled a range of epidemiological studies with wide-ranging applications[1]. Hospital admissions (HA) data are often used to identify individuals with disease, but this may result in incomplete ascertainment for conditions such as atrial fibrillation (AF), which often does not require hospitalisation. Understanding ascertainment through primary care (PC) data is essential to determine the potential benefits and drawbacks of using difference data sources for AF ascertainment. Purpose To explore potential differences between AF cases identified from PC and HA data with respect to participant characteristics, timing of ascertainment, and AF-related sequelae. Methods UK Biobank is a large prospective study with PC and HA data available in 230,000 participants[2]. Incident AF cases were defined using a combination of Read clinical codes in PC data and ICD-10 diagnostic and OPCS-4 procedural codes in HA data. Individuals were divided into 3 groups representing whether AF was defined using PC records only (PC-only), hospital admissions only (HA-only), or both (PC+HA). Descriptive statistics and multinomial regression were used to describe differences between groups in terms of ascertainment timing, risk factor associations, and post-AF stroke and death. Results During a median follow-up of 7 years, 7,142 incident AF cases were identified: 22% through PC-only (1571 new cases), 30% through HA-only, and 48% via PC+HA. In the latter group, when AF was first identified through PC (3827), there was an average lag of 1.3 years before it was identified in HA data, but a 5-year lag in the opposite direction (Figure 1). The patterns of associations for baseline age, sex, BMI, smoking, blood pressure, and composite clinical risk (CHARGE-AF[3]) suggested little evidence of systematic differences between the groups (Figure 2). However, the associations of AF with baseline diabetes, heart failure, myocardial infarction, and an AF polygenic risk score[4] suggested HA-only cases had a higher prevalence of cardiometabolic comorbities, but lower overall genetic AF risk. Moreover, HA-only AF cases had similar rates of subsequent stroke but substantially higher rates of death (73.2 per 1000 person-years) compared to the PC-only and PC+HA groups (6.6 and 23.1, respectively). Conclusion PC data identifies 28% additional AF cases than HA alone in UK Biobank, with important implications for the power of epidemiological studies. The strength of associations between risk factors and AF varies by ascertainment source, as do the rates of AF-related sequelae, suggesting that further studies comparing treatment in different groups may be warranted. Furthermore, for AF identified in HA alone, improved consistency and timeliness of routine recording of AF in PC may have important implications for management and risk of sequelae.

The impact on the elapsed time to care and outcomes of a clinician-to-clinician electronic consultation program in patients diagnosed or suspected atrial fibrillation in primary care

Abstract Background An early diagnosis and early initiation of oral anticoagulants (OAC) are main determinants for outcomes in patients with atrial fibrillation (AF). Clinician-to-clinician electronic consultations (e-consultations) program as the first step in the ambulatory care organization for the general practitioner (GPs) referrals to cardiologist may improve health care access by reducing the elapsed time for cardiology care compared with a face-to-face consultation for all the referrals. Objective To evaluate the effect on outcomes of a reduced elapsed time to care after a clinician-to-clinician e-consultations program implementation (2013–2019) in comparison with previous in-person consultation (2010–2012) in the outpatient health care management in a Cardiology Department. Methodology We included 10,488 patients referred by general care practitioners for cardiology consultation with confirmed or suspected AF from 1 January 2010, to 31 December 2019. Until 2012, all patients were attended with an in-person consultation (2010–2012). In 2013, we instituted an e-consult program (2013–2019) for all primary care referrals to cardiologists that preceded patient's in-person consultation when considered. The shared electronic patient dossier (EPD) was available between GP and cardiologist, and any clinical comment and change in therapy advice from cardiologist was directly implemented in this EPD. Results During the e-consultation period (2013–2019) were referred 6627 patients by GPs to cardiology versus 3861 during the in-person consultation (2010– 2012). The e-consultation implementation was associated with a reduction in the elapsed time to anticoagulation prescription (177.6 ±8.9 vs. 22.5 ±8.1 days,p < .001) (Figure 1, A), and an increase of OAC use (61% [95% IC: 19.6%–102.4%], p < .001) (Figure 1, B). The e-consult program implementation was associated with a reduction in the 1-year CV mortality (.48 [95% CI: .30–.75]) and all-cause mortality (.42 [95% CI: .29– .62]). The OAC reduces the stroke mortality (.15 [95% CI: .06–.39]) and CV mortality (.43 [95% CI: .29–.62]) and all-cause mortality (.23 [95% CI: .17–.31]) (Figure 2). Conclusion A shared EPD-based clinician-to-clinician e-consultation program significantly reduced the elapsed time for cardiology consultation and initiation of OAC. The implementation of this program was associated with a lower risk of stroke, cardiovascular and all-cause mortality.

The impact of inter-clinician electronic consultation in patients diagnosed with atrial fibrillation in primary care.

An early diagnosis and early initiation of oral anticoagulants (OAC) are main determinants for outcomes in patients with atrial fibrillation (AF). Inter-clinician electronic consultations (e-consultations) program for the general practitioner referrals to cardiologist may improve health care access by reducing the elapsed time for cardiology care. To evaluate the effect of a reduced elapsed time to care after a inter-clinician e-consultations program implementation (2013-2019) in comparison with previous in-person consultation (2010-2012) in the outpatient health care management in a Cardiology Department. We included 10,488 patients with AF from 1 January 2010, to 31 December 2019. Until 2012, all patients attended an in-person consultation (2010-2012). In 2013, we instituted an e-consult program (2013-2019) for all primary care referrals to cardiologists that preceded patient's in-person consultation when considered. The shared electronic patient dossier (EPD) was available between GP and cardiologist, and any change in therapy advice from cardiologist was directly implemented in this EPD. During the e-consultation period (2013-2019) were referred 6627 patients by GPs to cardiology versus 3861 during the in-person consultation (2010-2012). The e-consultation implementation was associated with a reduction in the elapsed time to anticoagulation prescription (177.6± 8.9 vs. 22.5± 8.1 days, p< .001), and an increase of OAC use (61% [95% IC: 19.6%-102.4%], p < .001). The e-consult program implementation was associated with a reduction in the 1-year CV mortality (.48 [95% CI: .30-.75]) and all-cause mortality (.42 [95% CI: .29-.62]). The OAC reduces the stroke mortality (.15 [95% CI: .06-.39]) and CV mortality (.43 [95% CI: .29-.62]) and all-cause mortality (.23 [95% CI: .17-.31]). A shared EPD-based inter-clinician e-consultation program significantly reduced the elapsed time for cardiology consultation and initiation of OAC. The implementation of this program was associated with a lower risk of stroke and cardiovascular/all-cause mortality.

Changes in primary care management of atrial fibrillation patients following the shift from warfarin to non-vitamin K antagonist oral anticoagulants: a Norwegian population based study

BackgroundTo assess baseline characteristics, drug utilisation and healthcare use for oral anticoagulants (OACs) following the introduction of non-vitamin K antagonist oral anticoagulants among patients with atrial fibrillation in primary care in Norway.MethodsIn this retrospective longitudinal cohort study, 92,936 patients with atrial fibrillation were identified from the Norwegian Primary Care Registry between 2010 and 2018. Linking to the Norwegian Prescription Database, we identified 64,112 patients (69.0%) treated with OACs and 28,824 (31%) who were untreated. Participants were followed until 15 May 2019, death, or loss to follow-up, whichever came first. For each OAC, predictors of initiation were assessed by modelling the probability of initiating the OAC using logistic regression, and predictors of the first switch after index date were assessed using multivariable Cox proportional hazards models. The numbers of primary care visits per quarter by index OAC were plotted and analysed with negative binomial regression analyses offset for the log of days at risk.ResultsPatients treated with OACs were older, had more comorbidities, and higher CHA2DS2-VASc scores than untreated patients. However, the mean CHA2DS2-VASc in the non-OAC group was 1.58 for men and 3.13 for women, suggesting an indication for OAC therapy. The percentage of patients with atrial fibrillation initiating OACs increased from 59% in 2010 to 79% in 2018. Non-vitamin K antagonist oral anticoagulant use increased throughout the study period to 95% of new OAC-treated patients in 2018, and switches from warfarin to non-vitamin K antagonist oral anticoagulants were common. The persistence of OAC treatment was > 60% after four years, with greatest persistence for apixaban. Patients treated with non-vitamin K antagonist oral anticoagulants had fewer primary care visits compared with those treated with warfarin (incidence rate ratio: 0.73, 95% confidence interval 0.71 to 0.75).ConclusionIn this Norwegian primary care study, we found that the shift from warfarin to non-vitamin K antagonist oral anticoagulants was successful with 95% use in patients initiating OACs in 2018, and associated with fewer general practitioner visits. Persistence with OACs was high, particularly for apixaban. However, many patients eligible for treatment with OACs remained untreated.

Detection of hidden atrial fibrillation in primary care using a long-term band-based ECG registration system: The DESCUUBRE-FA study

ObjectiveTo assess whether the use of a band-based electrocardiographic (ECG) monitoring system improves the diagnostic accuracy of traditional diagnostic methods for the detection of atrial fibrillation (AF). MethodsMulticenter and observational study of primary care patients at risk of AF. To be included, patients had to be aged ≥70 years, with no known AF, and have at least 1 major criterion (obesity, hyperthyroidism, heart failure) or 2 minor criteria (hypertension, diabetes, female sex, ischemic stroke, transient ischemic attack or systemic embolism, COPD, dyslipidemia, ischemic heart disease, peripheral artery disease). All patients were monitored using the Nuubo™ system for a single 2-week period. ResultsA total of 600 patients were included (median age 77 years; 70% women; 84.3% hypertension, 27.2% diabetes, 9.2% prior stroke). The global rate of diagnosis of new AF in the overall population was 2.83%. All patients with AF were anticoagulated. In numerical terms, patients with AF (vs no AF) had a higher number of supraventricular extrasystoles and episodes of supraventricular tachycardia, as well as longer P wave duration; however, these differences did not reach statistical significance. Overall, participants were very satisfied with the device, and no relevant limitations in daily activities were observed during the 2-week study period. ConclusionsIn an elderly population at risk of AF, a band-based ECG monitoring approach applied for only 2 weeks detected approximately 3% of new cases of AF, leading to a change in antithrombotic therapy. Most participants considered the device easy to use and comfortable.

Detection of atrial fibrillation in primary care with radial pulse palpation, electronic blood pressure measurement and handheld single-lead electrocardiography: a diagnostic accuracy study

ObjectiveTo determine the diagnostic accuracy of three tests—radial pulse palpation, an electronic blood pressure monitor and a handheld single-lead ECG device—for opportunistic screening for unknown atrial fibrillation (AF).DesignWe performed a...

Optimal opportunistic screening of atrial fibrillation using pulse palpation in cardiology outpatient clinics: Who and how.

Atrial fibrillation (AF) remain a prevalent undiagnosed condition frequently encountered in primary care. We aimed to find the parameters that optimize the diagnostic accuracy of pulse palpation to detect AF. We also aimed to create a simple algorithm for selecting which individuals would benefit from pulse palpation and, if positive, receive an ECG to detect AF. Nurses from four Cardiology outpatient clinics palpated 7,844 pulses according to a randomized list of arterial territories and durations of measure and immediately followed by a 12-lead ECG, which we used as the reference standard. We calculated the sensitivity and specificity of the palpation parameters. We also assessed whether diagnostic accuracy depended on the nurse's experience or on a list of clinical factors of the patients. With this information, we estimated the positive predictive values and false omission rates according to very few clinical factors readily available in primary care (age, sex, and diagnosis of heart failure) and used them to create the algorithm. The parameters associated with the highest diagnostic accuracy were palpation of the radial artery and classifying as irregular those palpations in which the nurse was uncertain about pulse regularity or unable to palpate pulse (sensitivity = 79%; specificity = 86%). Specificity decreased with age. Neither the nurse's experience nor any investigated clinical factor influenced diagnostic accuracy. We provide the algorithm to select the ≥40 years old individuals that would benefit from a pulse palpation screening: a) do nothing in <60 years old individuals without heart failure; b) do ECG in ≥70 years old individuals with heart failure; c) do radial pulse palpation in the remaining individuals and do ECG if the pulse is irregular or you are uncertain about its regularity or unable to palpate it. Opportunistic screening for AF using optimal pulse palpation in candidate individuals according to a simple algorithm may have high effectiveness in detecting AF in primary care.

Sleep apnea and atrial fibrillation: the spell of Groundhog Day.

Sleep apnea and atrial fibrillation: the spell of Groundhog Day.

Screening for paroxysmal atrial fibrillation in primary care using Holter monitoring and intermittent, ambulatory single-lead electrocardiography

Background: Timely detection of atrial fibrillation (AF) is important because of its increased risk of thrombo-embolic events. Single time point screening interventions fall short in detection of paroxysmal AF, which requires prolonged electrocardiographic monitoring, usually using a Holter. However, traditional 24-48 h Holter monitoring is less appropriate for screening purposes because of its low diagnostic yield. Intermittent, ambulatory screening using a single-lead electrocardiogram (1 L-ECG) device can offer a more efficient alternative.Methods: Primary care patients of ≥65 years participated in an opportunistic screening study for AF. We invited patients with a negative 12 L-ECG to wear a Holter monitor for two weeks and to use a MyDiagnostick 1 L-ECG device thrice daily. We report the yield of paroxysmal AF found by Holter monitoring and calculate the diagnostic accuracy of the 1 L-ECG device's built-in AF detection algorithm with the Holter monitor as reference standard.Results: We included 270 patients, of whom four had AF in a median of 8.0 days of Holter monitoring, a diagnostic yield of 1.5% (95%-CI: 0.4–3.8%). In 205 patients we performed simultaneous 1 L-ECG screening. For diagnosing AF based on the 1 L-ECG device's AF detection algorithm, sensitivity was 66.7% (95%-CI: 9.4–99.2%), specificity 68.8% (95%-CI: 61.9–75.1%), positive predictive value 3.1% (95%-CI: 1.4–6.8%) and negative predictive value 99.3% (95%-CI: 96.6–99.9%).Conclusion: We found a low diagnostic yield of paroxysmal AF using Holter monitoring in elderly primary care patients with a negative 12 L-ECG. The diagnostic accuracy of an intermittently, ambulatory used MyDiagnostick 1 L-ECG device as interpreted by its built-in AF detection algorithm is limited.

Gender and Socioeconomic Inequality in the Prescription of Direct Oral Anticoagulants in Patients with Non-Valvular Atrial Fibrillation in Primary Care in Catalonia (Fantas-TIC Study).

Background: Evidence points to unequal access to direct oral anticoagulant (DOAC) therapy, to the detriment of the most socioeconomically disadvantaged patients in different geographic areas; however, few studies have focused on people with atrial fibrillation. This study aimed to assess gender-based and socioeconomic differences in the prescriptions of anticoagulants in people with non-valvular atrial fibrillation who attended Primary Care. Method: A cross-sectional study with real-world data from patients treated in Primary Care in Catalonia (Spain). Data were obtained from the SIDIAP database, covering 287 Primary Care centers in 2018. Results were presented as descriptive statistics and odds ratios estimated by multivariable logistic regression. Results: A total of 60,978 patients on anticoagulants for non-valvular atrial fibrillation were identified: 41,430 (68%) were taking vitamin K antagonists and 19,548 (32%), DOACs. Women had higher odds of treatment with DOAC (adjusted odds ratio [ORadj] 1.12), while lower DOAC prescription rates affected patients from Primary Care centers located in high-deprivation urban centers (ORadj 0.58) and rural areas (ORadj 0.34). Conclusions: DOAC prescription patterns differ by population. Women are more likely to receive it than men, while people living in rural areas and deprived urban areas are less likely to receive this therapy. Following clinical management guidelines could help to minimize the inequality.

Yield of two week holter monitoring and diagnostic accuracy of intermittent single-lead electrocardiogram recordings in screening for paroxysmal atrial fibrillation in primary care

Abstract Background Timely detection of atrial fibrillation (AF) is important because of its increased risk of thrombo-embolic events. Single time point screening interventions for AF are hindered because of AF's often paroxysmal nature. Community based prevalence of paroxysmal AF (pAF), however, is scarcely investigated. To detect pAF, often a Holter for prolonged electrocardiographic monitoring is used. Holter monitoring, however, is less appropriate for screening purposes because of its high burden for asymptomatic patients. Intermittent screening using a single-lead electrocardiogram (1L-ECG) device can offer a less burdensome alternative. Purpose To determine A) the diagnostic yield of two week Holter monitoring in screening for pAF after a negative 12-lead (12L-)ECG, B) the diagnostic accuracy of an intermittently used 1L-ECG device, and C) how often an expert panel is able to accurately diagnose AF by visually assessing the 1L-ECG recordings of patients with ≥1 algorithm-positive 1L-ECG recording(s). We used the Holter monitor as reference standard. Methods Patients of 65 years and older participated in an opportunistic screening study for AF. They received three screening tests (pulse palpation, electronic sphygmomanometer and a 1L-ECG device both with built-in AF detection algorithm). A 12L-ECG was recorded whenever at least one screening test was positive, supplemented with 10% of patients with three negative tests. We invited patients with a negative 12L-ECG to use a 1L-ECG device thrice daily and perform Holter monitoring for two weeks. We report the prevalence of pAF found by Holter monitoring and calculate the diagnostic accuracy of the 1L-ECG device's built-in AF detection algorithm. All 1L-ECG recordings of patients with ≥1 positive algorithm result were subsequently visually assessed by an expert panel of three cardiologists. Results We included 270 patients, of whom four had pAF on a median of 8.5 days of Holter monitoring: prevalence 1.5% (95%-CI: 0.4–3.8%). 205 patients were simultaneously screened with 1L-ECG recordings and Holter monitoring. Sensitivity was 67% (95%-CI: 9–99%), specificity 69% (95%-CI: 62–75%), positive predictive value 3% (95%-CI: 1–7%) and negative predictive value 99% (95%-CI: 97–100%) for diagnosing pAF based on the 1L-ECG device's built-in AF detection algorithm. Out of 65 patients with ≥1 algorithm-positive 1L-ECG recording(s), seven were classified as pAF after visual assessment by the expert panel. Six of these were false-positive. In 24 cases the expert panel could not interpret the 1L-ECGs. Conclusion We found a low prevalence of pAF using Holter monitoring in elderly primary care patients, with a negative 12L-ECG. The diagnostic accuracy of the built-in AF detection algorithm of an intermittently used 1L-ECG device is limited with a high false-positive rate. Cardiologists' assessment of algorithm-positive intermittent 1L-ECGs did not sufficiently improve accuracy to make a reliable diagnosis. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by ZonMw (The Netherlands Organisation for Health Research and Development)

Anticoagulation Control with Acenocoumarol or Warfarin in Non-Valvular Atrial Fibrillation in Primary Care (Fantas-TIC Study).

Introduction: The use of vitamin K antagonists (VKAs) in non-valvular atrial fibrillation (NVAF) is complicated due to the narrow therapeutic margin they present and their unpredictable dose–response relationship. Most studies are based on warfarin, with the results being extrapolated to acenocoumarol. However, studies comparing the two treatments in terms of the degree of anticoagulation control are scarce, justifying the present study. Main factors associated with poor control of time in therapeutic range (TTR) of anticoagulated patients are also studied. Methods: Cross-sectional study, with real-world data from patients treated in primary care (PC). Data were obtained from the System for the Improvement of Research in PC (SIDIAP) database, covering 60,978 NVAF-anticoagulated patients from 287 PC centres in 2018. Descriptive statistics were derived, and odds ratios were estimated by multivariate logistic regression. Results: 41,430 patients were considered: 93% were being treated with acenocoumarol and 7% with warfarin. There was no difference in poor control of TTR between the two types of VKA treatment, acenocoumarol and warfarin (38.9 vs. 38.4; p = 0.610). Poor anticoagulation control was mainly associated with advanced alcoholism (OR = 1.38), liver failure (OR = 1.37) and intracranial haemorrhage (OR = 1.35) as well as female sex, age < 60 years, cardiovascular history, diabetes mellitus and other variables. Conclusions: There is no association between poor anticoagulation control and the type of VKA treatment administered. Factors associated with poor control of TTR must be considered in clinical practice to improve control and decision-making.

Oral Anticoagulant Adequacy in Non-Valvular Atrial Fibrillation in Primary Care: A Cross-Sectional Study Using Real-World Data (Fantas-TIC Study).

Background: Oral anticoagulants (OAs) are the treatment to prevent stroke in atrial fibrillation (AF). Anticoagulant treatment choice in non-valvular atrial fibrillation (NVAF) must be individualized, taking current guidelines into account. Adequacy of anticoagulant therapy under the current criteria for NVAF in real-world primary care is presented. Methods: Cross-sectional study, with real-world data from patients treated in primary care (PC). Data were obtained from the System for the Improvement of Research in Primary Care (SIDIAP) database, covering 60,978 NVAF-anticoagulated patients from 287 PC centers in 2018. Results: In total, 41,430 (68%) were treated with vitamin K antagonists (VKAs) and 19,548 (32%) NVAF with direct-acting oral anticoagulants (DOACs). Inadequate prescription was estimated to be 36.0% and 67.6%, respectively. Most DOAC inadequacy (77.3%) was due to it being prescribed as a first-line anticoagulant when there was no history of thromboembolic events or intracranial hemorrhage (ICH). A total of 22.1% had missing estimated glomerular filtration rate (eGFR) values. Common causes of inadequate VKA prescription were poor control of time in therapeutic range (TTR) (98.8%) and ICH (2.2%). Conclusions: Poor adequacy to current criteria was observed, being inadequacy higher in DOACs than in VKAs. TTR and GFR should be routinely calculated in electronic health records (EHR) to facilitate decision-making and patient safety.

Evaluating the use of a mobile device for detection of atrial fibrillation in primary care.

Evaluating the use of a mobile device for detection of atrial fibrillation in primary care.

Evaluating the use of a mobile device for detection of atrial fibrillation in primary care.

A trial fibrillation (AF) increases cardio-embolic stroke risk, yet AF diagnosis and subsequent prophylactic anticoagulant prescription rates are suboptimal globally. This project aimed to increase AF diagnosis and subsequent anticoagulation prescription rates in East Midlands Clinical Commissioning Groups (CCGs). This service improvement evaluation of the East Midlands AF Advance programme investigated the implementation of mobile AF detection devices (Kardia, AliveCor) into primary-care practices within East Midlands CCGs, along with audit tools and clinician upskilling workshops designed to increase AF diagnosis and anticoagulation prescription rates. AF prevalence and prescription data were collected quarterly from July to September (Q3) 2017/18 to April to June/July to September (Q2/3) 2018/19. AF prevalence increased from 1.9% (22,975 diagnoses) in Q3 2017/18 to 2.4% (24,246 diagnoses) in Q2 2018/19 (p=0.026), while the percentage of high-risk AF patients receiving anticoagulants increased from 80.5% in Q3 2017/18 to 86.9% in Q3 2018/19 (p=0.57), surpassing the Public Health England 2019 target of 85%. The East Midlands AF Advance programme increased AF diagnosis and anticoagulation rates, which is expected to be of significant clinical benefit. The mobile AF detection devices provide a more practical alternative to traditional 12-lead electrocardiograms (ECGs) and should be incorporated into routine clinical practice for opportunistic AF detection, in combination with medication reviews to increase anticoagulant prescription.

Temporal trends in incidence of atrial fibrillation in primary care records: a population-based cohort study

ObjectivesAtrial fibrillation (AF) is a heart condition associated with a fivefold increased risk of stroke. The condition can be detected in primary care and treatment can greatly reduce the risk...