Screening For AF Research Articles

PPGAF-score: a photoplethysmographic risk prediction tool for developing atrial fibrillation

Abstract Background Digital screening for AF was recently shown to significantly increased the detection rate of treatment-relevant AF when compared to usual care. In this post-hoc analysis of the eBRAVE-AF trial, we hypothesized that information derived from sequential PPG-measurements in sinus rhythm might be predictive for future AF-development and we aimed to develop a dynamic AF-risk score (PPGAF-score). Methods In eBRAVE-AF, individuals who were free of AF were randomized to digital screening or usual care. For digital screening, participants screened for irregularities by means of PPG and abnormal findings were confirmed by a 14-day Holter-ECG. The primary endpoint was newly diagnosed AF treated with oral anticoagulation (OAC) within 6 months. After 6 months, participants were invited to a second, cross-over study phase. In this sub-study we identified participants who performed PPG-measurements both on day (8 am-6 pm) and at night (10 pm-6 am). PPGAF-score was calculated using the coefficients derived from Cox regression analysis. The multivariable model included age ≥ 65 years, sex and three PPG-derived parameters: (i) mean heart rate (HR) of each single PPG-measurement and (ii) the standard deviation (SD) of the HR between subsequent PPG-measurements, which were both dichotomized at the median value and (iii) the failure to demonstrate nocturnal HR reduction (day HR/night HR < 1). PPGAF-score was dichotomized at the median value. Results Of the 2,436 participants included in this analysis, 1,208 (50%) were ≥ 65 years old and 776 (32%) participants were females. Cumulatively 186,551 PPG measurements were performed, corresponding to a median of 28 (IQR 23) daytime and 3 (IQR 5) nighttime measurements per participant. The median HR per measurement was 69 (IQR 11) bpm, the median SD of the HR was 6 (IQR 2) bpm, and 759 (31%) participants failed to show a nocturnal HR reduction. During a follow-up time of 12 months, 53 subjects reached the primary endpoint. Cox regression analysis showed that age ≥ 65 years (HR 3.6; 95% CI 1.9–7.0; p < 0.001), male sex (2.7; 95% CI 1.2–5.9;p = 0.017), HR < 69bpm (HR 1.9; 95% CI 1.1–3.5;p=0.028), SD of HR ≥ 6bpm (HR 2.2; 95% CI 1.2–4.0;p=0.011) and the failure to show nocturnal HR reduction (HR 3.2; 95% CI 1.9–5.5; p < 0.001) were all independent predictors of the primary endpoint. PPGAF-score was calculated from the multivariable model. The median value was 0.22. PPGAF-score > 0.22 compared to a risk score ≤ 0.22 was associated with a significantly higher risk for developing AF requiring OAC (HR 6.9, 95% CI 3.1–15.4;p < 0.001; Figure 1). Conclusion Combining demographic and PPG-derived parameters, we developed a dynamic prediction tool for assessing the one-year risk of developing AF requiring OAC. A risk score of > 0.22 was associated with a 7-fold increased risk for developing treatment-relevant AF. PPG recordings might provide a valuable tool not only for diagnosing AF, but also for selecting high-risk individuals.

Effect of Screening for Undiagnosed Atrial Fibrillation on Stroke Prevention

BackgroundAtrial fibrillation (AF) often remains undiagnosed, and it independently raises the risk of ischemic stroke, which is largely reversible by oral anticoagulation. Although randomized trials using longer term screening approaches increase identification of AF, no studies have established that AF screening lowers stroke rates. ObjectivesTo address this knowledge gap, the GUARD-AF (Reducing Stroke by Screening for Undiagnosed Atrial Fibrillation in Elderly Individuals) trial screened participants in primary care practices using a 14-day continuous electrocardiographic monitor to determine whether screening for AF coupled with physician/patient decision-making to use oral anticoagulation reduces stroke and provides a net clinical benefit compared with usual care. MethodsGUARD-AF was a prospective, parallel-group, randomized controlled trial designed to test whether screening for AF in people aged ≥70 years using a 14-day single-lead continuous electrocardiographic patch monitor could identify patients with undiagnosed AF and reduce stroke. Participants were randomized 1:1 to screening or usual care. The primary efficacy and safety outcomes were hospitalization due to all-cause stroke and bleeding, respectively. Analyses used the intention-to-treat population. ResultsEnrollment began on December 17, 2019, and involved 149 primary care sites across the United States. The COVID-19 pandemic led to premature termination of enrollment, with 11,905 participants in the intention-to-treat population. Median follow-up was 15.3 months (Q1-Q3: 13.8-17.6 months). Median age was 75 years (Q1-Q3: 72-79 years), and 56.6% were female. The risk of stroke in the screening group was 0.7% vs 0.6% in the usual care group (HR: 1.10; 95% CI: 0.69-1.75). The risk of bleeding was 1.0% in the screening group vs 1.1% in the usual care group (HR: 0.87; 95% CI: 0.60-1.26). Diagnosis of AF was 5% in the screening group and 3.3% in the usual care group, and initiation of oral anticoagulation after randomization was 4.2% and 2.8%, respectively. ConclusionsIn this trial, there was no evidence that screening for AF using a 14-day continuous electrocardiographic monitor in people ≥70 years of age seen in primary care practice reduces stroke hospitalizations. Event rates were low, however, and the trial did not enroll the planned sample size.(Reducing Stroke by Screening for Undiagnosed Atrial Fibrillation in Elderly Individuals [GUARD-AF]; NCT04126486)

Burden of atrial fibrillation risk and outcomes amongst patients attending cardiology and elderly medicine services: prospective in-hospital implementation of the FIND-AF algorithm

Abstract Background Screening for silent AF is becoming increasingly important (1, 2), and the FIND-AF algorithms can use routinely-collected data to identify individuals at higher risk for undiagnosed AF (3). There may be a much higher prevalence of patients at risk for AF and its complications in a hospital environment compared with the community (4). Purpose We prospectively implemented the FIND-AF algorithm within cardiology and geriatric services to quantify the burden of AF risk amongst all-comers, and to understand their outcomes over the next 6 months. Methods We prospectively implemented the FIND-AF algorithm in the cardiology and geriatric departments of three UK hospitals for consecutive inpatient or outpatient attendances from February 1 to July 13th 2023. We assessed the number of individuals attending each service eligible for an AF screening protocol (exclusion criteria: age <30 years, history of AF, on a palliative care pathway, use of oral anticoagulation), and calculated the burden of AF risk in each service. Patients were followed up for 6 months for the primary outcome of incident AF, heart failure (HF), stroke/transient ischaemic attack (TIA)/systemic embolism, and death. Incident diagnoses were the first record of that condition in primary or secondary care records. Rate ratios (RRs) with 95% confidence intervals (CIs) for combined incident cardiovascular outcomes or death were derived through Poisson regression for predicted higher versus lower AF risk. Results Of 467 consecutive patients, 364 were eligible for AF screening. 66 were excluded due to a previous diagnosis of AF, 25 were already prescribed a long-term oral anticoagulant, 5 were on a palliative care pathway and 7 were aged <30 years. Baseline characteristics of each cohort are summarised in Table 1. Of patients eligible for AF screening, those attending geriatrics were at higher risk of incident AF than patients attending cardiology (median FIND-AF score: geriatrics, 0.015, 95% CI 0.008 - 0.024; cardiology, 0.005, 95% CI 0.001-0.015; p<0.05; distributions of risk summarised in Figure 1) and had a higher stroke risk. Absolute risk of AF was greater than 5% within the next 6 months for 11.6% and 9.1% of geriatric and cardiology patients, respectively. Of the eligible cohort, 328 had follow up at 6 months, with 46 experiencing the primary outcome (9, 7, 3, and 27 recorded cases of AF, HF, stroke/TIA, and death, respectively). The higher predicted risk cohort, compared to lower predicted risk, had a higher risk of combined incident AF, heart failure, or stroke/TIA/systemic embolism (Rate ratio: 5.59, 95% CI 1.13-101.01) and death (RR 9.68, 2.06-172.85). Conclusions The FIND-AF algorithm can be prospectively implemented in hospital records to identify cardiology and geriatric patients at risk of incident AF, heart failure, thromboembolic disease and death. There is an opportunity to conduct risk-guided screening in the context of hospital attendances.

Atrial electrofunctional predictors of incident atrial fibrillation in cardiac amyloidosis

BackgroundAtrial fibrillation (AF) is common in patients with cardiac amyloidosis (CA) and is a significant risk factor for heart failure hospitalization and thromboembolic events. ObjectiveThis study was designed to investigate the atrial electrofunctional predictors of incident AF in CA. MethodsA multicenter, observational study was conducted in 4 CA referral centers including sinus rhythm patients with light-chain (AL) and transthyretin (ATTR) CA undergoing electrocardiography and cardiac magnetic resonance imaging. The primary end point was new-onset AF occurrence. ResultsOverall, 96 patients (AL-CA, n = 40; ATTR-CA, n = 56) were enrolled. During an 18-month median follow-up (Q1–Q3, 7–29 months), 30 patients (29%) had incident AF. Compared with those without AF, patients with AF were older (79 vs 73 years; P = .001). They more frequently had ATTR (87% vs 45%; P < .001); electrocardiographic interatrial block (IAB), either partial (47% vs 21%; P = .011) or advanced (17% vs 3%; P = .017); and lower left atrial ejection fraction (LAEF; 29% vs 41%; P = .004). Age (hazard ratio [HR], 1.059; 95% CI, 1.002–1.118; P = .042), any type of IAB (HR, 2.211; 95% CI, 1.03–4.75; P = .041), and LAEF (HR, 0.967; 95% CI, 0.936–0.998; P = .044) emerged as independent predictors of incident AF. Patients exhibiting any type of IAB, LAEF <40%, and age >78 years showed a cumulative incidence for AF of 40% at 12 months. This risk was significantly higher than that carried by 1 (8.5%) or none (7.6%) of these 3 risk factors. ConclusionIn patients with CA, older age, IAB on 12-lead electrocardiography, and reduced LAEF on cardiac magnetic resonance imaging are significant and independent predictors of incident AF. A closer screening for AF is advisable in CA patients carrying these features.

New-onset atrial fibrillation in chronic coronary syndrome outpatients. Insights from the international CLARIFY registry

Abstract Background and Aims Data on new-onset atrial fibrillation (NOAF) in patients with chronic coronary syndromes (CCS) are scarce. This study aims to describe the incidence, predictors and impact on cardiovascular outcomes of NOAF in CCS patients. Methods Data from the international (45 countries) CLARIFY registry (prospeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) were used. Among 29,001 CCS outpatients without previously reported AF at baseline, patients with at least one episode of AF/flutter diagnosed during 5-year follow-up were compared with patients in sinus rhythm throughout the study. Results The incidence rate of NOAF was 1.12 [95% confidence interval (CI) 1.06-1.18] per 100 patients-year (cumulative incidence at five years: 5.0%). Independent predictors of NOAF were increasing age, increasing body mass index, treated hypertension, history of peripheral artery disease, alcohol intake and low left ventricular ejection fraction, while high triglycerides were associated with lower incidence. NOAF was associated with a substantial increase in the risk of adverse outcomes, with adjusted hazard ratios of 2.52 (95%CI 2.11-3.01) for the composite of cardiovascular death, myocardial infarction or stroke, 3.22 (95%CI 2.63-3.94) for cardiovascular death, 1.55 (95%CI 1.08-2.22) for myocardial infarction, 2.80 (95%CI 2.0-3.91) for stroke, 2.64 (95%CI 2.23-3.11) for all cause death, 9.38 (95%CI 8.02-10.97) for hospitalization for heart failure and 4.33 (95%CI 2.94-6.39) for major bleeding. Conclusion Among CCS patients, NOAF is common and is strongly associated with worse outcomes. Whether more intensive preventive measures and more systematic screening for AF would improve prognosis in this population deserves further investigation.FlowchartGraphical Abstract

New-onset atrial fibrillation and chronic coronary syndrome in the CLARIFY registry.

Data on new-onset atrial fibrillation (NOAF) in patients with chronic coronary syndromes (CCS) are scarce. This study aims to describe the incidence, predictors, and impact on cardiovascular (CV) outcomes of NOAF in CCS patients. Data from the international (45 countries) CLARIFY registry (prospeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) were used. Among 29 001 CCS outpatients without previously reported AF at baseline, patients with at least one episode of AF/flutter diagnosed during 5-year follow-up were compared with patients in sinus rhythm throughout the study. The incidence rate of NOAF was 1.12 [95% confidence interval (CI) 1.06-1.18] per 100 patient-years (cumulative incidence at 5 years: 5.0%). Independent predictors of NOAF were increasing age, increasing body mass index, low estimated glomerular filtration rate, Caucasian ethnicity, alcohol intake, and low left ventricular ejection fraction, while high triglycerides were associated with lower incidence. New-onset atrial fibrillation was associated with a substantial increase in the risk of adverse outcomes, with adjusted hazard ratios of 2.01 (95% CI 1.61-2.52) for the composite of CV death, non-fatal myocardial infarction, or non-fatal stroke, 2.61 (95% CI 2.04-3.34) for CV death, 1.64 (95% CI 1.07-2.50) for non-fatal myocardial infarction, 2.27 (95% CI 1.85-2.78) for all-cause death, 8.44 (95% CI 7.05-10.10) for hospitalization for heart failure, and 4.46 (95% CI 2.85-6.99) for major bleeding. Among CCS patients, NOAF is common and is strongly associated with worse outcomes. Whether more intensive preventive measures and more systematic screening for AF would improve prognosis in this population deserves further investigation.

Thrombosis risk factors in patients with atrial fibrillation according to the CHA2DS2-VASc scales depending on the previous COVID-19 infection

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): In. of cardiology Introduction The disease COVID-19, caused by the SARS-CoV-2 coronavirus, is characterized by an increase in the inflammatory response from all systems of the human body, which, in turn, can lead to such a serious complication as coagulopathy. Purpose To evaluate the risk factors of thromboembolismaccording to the CHA2DS2-VASc scale in patients with AF depending on the previous coronavirus infection (CI). Materials and methods The study included 187 patients aged 62.5±0.9 years (47% men, 53% women). The vast majority of patients (89%) had arterial hypertension (II stage – 80%, III stage – 9%). Chronic forms of coronary heart disease were diagnosed in 53% of patients. The first three groups formed 116 patients who had AF and underwent coronavirus infection (CI). The first group (G1) consisted of 36 patients who did not have AF before CI. The second group (G2) was represented by 25 patients in whom the transition of the paroxysmal form of AF into persistent, or persistent AF into its permanent form occurred. The third group (G3) consisted of 55 patients in whom the form of AF did not change, but in 35 of them the frequency or duration of AF paroxysms increased (subgroup 3a), and in 20 people the frequency or duration of AF paroxysms did not change (subgroup 3b). Two control groups were also formed: K1 - 49 patients with AF who did not have a history of HF, and K2 - 22 patients with extrasystole who experienced HF, but who did not develop AF. Results In the course of the work, it was established that patients of the 1st, 2nd and 3rd groups, compared to patients of the first control group, when evaluating the average points on the CHADS2-VASc scale, had a higher risk of thromboembolism (3,06 vs. 2,90, p &amp;lt; 0.001 ). In a detailed analysis of the number of patients who had CHA2DS2VASc - 0 - 2 points and CHA2DS2VASc - ≥ 2 points per minute. of the examined groups, it was found that there were more people with a high risk of thrombus formation among AF patients who underwent CI. In the 1st group (72.2% vs. 27.8%, p &amp;lt; 0.01), in the 2nd group (68% vs. 32%, p &amp;lt; 0.01) and the 3rd group (70.9 % versus 29.1%, p &amp;lt; 0.01). Patients of subgroup 3a compared to subgroup 3b had a higher percentage of complications such as cerebral stroke and TIA in the anamnesis (8.6% vs. 0%), that is, these complications worsen the course of AF after CI. Conclusions In patients with newly registered paroxysms of AF or in patients in whom the course of existing AF worsened against the background of a previous CI, there were significantly higher risks of thrombus formation according to the CHA2DS2-VASc scale. Special attention is drawn to patients who did not have this arrhythmia before CI, but who after its occurrence have a higher risk of cardioembolic complications. This indicates the need for prevention of thromboembolism and careful screening for AF.

Adherence to a mobile health-based atrial fibrillation screening program: a subanalysis from STROKESTOP I and II

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Stockholm County Council, the Swedish Heart &amp; Lung Foundation Introduction Atrial fibrillation (AF) is associated with an increased risk of stroke, which may be reduced through timely and adequate treatment initiation. Consequently, early detection of AF is important. In a recent European Heart Rhythm Association practical guide on the use of digital devices, systematic screening for AF of those ≥75 years is recommended. Purpose To 1) evaluate adherence and adherence consistency to a handheld electrocardiography (ECG)-based device for AF screening and 2) evaluate factors associated with optimal adherence and adherence consistency. Methods In STROKESTOP I and II, half of the 75- and 76-year old population in up to two regions in Sweden were invited to an AF screening program. Participants without previously known AF and without AF during baseline visit, were asked to perform 30-seconds recordings using a handheld ECG-based device for a period of two weeks twice daily in STROKESTOP I and four times a day in STROKESTOP II. Adherence was defined as the number of recordings performed per number of recordings that were asked from the participant over the entire screening period. Adherence consistency was defined as full screening days, i.e. the number of screening days on which the asked number of recordings was performed. Since baseline date was excluded from analysis, the total screening period consisted of 13 days. Results In total, 6436 participants from STROKESTOP I (3585 females (55.7%)) and 3712 participants from STROKESTOP II (2218 females (59.8%)) were included in the current analysis. Median adherence was 100% [92-100%] and 90% [75-98%] in STROKESTOP I and II, respectively. The median number of full screening days was 12 [11-13] in STROKESTOP I and 8 [3-11] in STROKESTOP II. In STROKESTOP I, female sex, region of inclusion, income in 1st to 3rd quartile and no university or college education were factors independently associated with both optimal adherence and adherence consistency (Figure 1). In addition, no previous stroke or transient ischemic attack and the use of beta blockers were associated with optimal adherence, whereas no diabetes and low alcohol index were associated with optimal adherence consistency. In STROKESTOP II, socioeconomic factors were not available at the time of the current analysis. Other associations (female sex, absence of diabetes) were comparable to STROKESTOP I. Conclusions In this screening program for AF, median adherence was optimal in case of twice daily measurements, and nearly optimal in case of measurements four times a day. Several demographic and socioeconomic factors, as well as low alcohol index and the absence of diabetes and previous stroke were associated with optimal adherence and/or adherence consistency.

Atrial fibrillation in young hospitalized patients: Clinical characteristics, predictors of new onset, and outcomes

BackgroundAtrial fibrillation (AF) in young adults is an uncommon and not well studied entity. MethodsConsecutive patients aged 18–45 years admitted to internal or cardiology services in a large tertiary medical center (January 1, 2009 through December 31, 2019) were included. Clinical, electrocardiographic, and echocardiographic data were compared between patients with and without AF at baseline. Predictors of new-onset AF in the young were identified using multivariate Cox regression model among patients free of baseline AF. ResultsFinal cohort included 16,432 patients with median age of 34 (IQR 26–41) years of whom 8914 (56 %) were men. Patients with AF at baseline (N = 366; 2 %) were older, more likely to be men, and had higher proportion of comorbidities and electrocardiographic conduction disorders. Male sex, increased age, obesity, heart failure, congenital heart disease (CHD) and the presence of left or right bundle branch block were all independently associated with baseline AF in a multivariate model (p < 0.001 for all). Sub-analysis of 10,691 (98 %) patients free of baseline AF identified 85 cases of new-onset AF during a median follow up of 3.5 (IQR 1.5–6.5) years. Multivariate model identified increased age, heart failure, and CHD as independent predictors of new-onset AF. Finally, the CHARGE-AF risk score outperformed the CHA2DS2-VASc score in AF prediction [AUC of ROC 0.75 (0.7–0.8) vs. 0.56 (0.48–0.65)]. ConclusionsAF among hospitalized young adults is not rare. Screening for new-onset AF in young post hospitalization patients may be guided by specific clinical predictors and the CHARGE-AF risk score.

EE381 Cost-Effectiveness Analysis of Atrial Fibrillation Screening in the Elderly Population of Taiwan

Screening for undiagnosed AF can identify patients who could benefit from anticoagulant therapy and reduce the burden of ischemic stroke (IS) through early intervention. The aim of this study was to evaluate whether population screening for AF in Taiwan could be cost-effective from a government perspective.

Prevalence of atrial fibrillation in Northern Sri Lanka: a study protocol for a cross-sectional household survey

IntroductionAtrial fibrillation (AF) is the most common arrhythmia globally. It is associated with a fivefold risk in stroke, but early diagnosis and effective treatment can reduce this risk. AF is...

Cluster randomised controlled trial of screening for atrial fibrillation in people aged 70 years and over to reduce stroke: protocol for the pilot study for the SAFER trial

IntroductionAtrial fibrillation (AF) is a common arrhythmia associated with 30% of strokes, as well as other cardiovascular disease, dementia and death. AF meets many criteria for screening, but there is...

Severity and Etiology of Incident Stroke in Patients Screened for Atrial Fibrillation vs Usual Care and the Impact of Prior Stroke

Atrial fibrillation (AF) screening trials have failed to demonstrate a significant reduction in stroke risk. The impact on stroke severity and the importance of prior strokes are unknown. To assess stroke characteristics in patients undergoing implantable loop recorder (ILR) screening for AF vs usual care and assess the importance of prior stroke. This was a post hoc analysis of the Atrial Fibrillation Detected by Continuous Electrocardiogram Monitoring Using Implantable Loop Recorder to Prevent Stroke in High-Risk Individuals (LOOP) randomized clinical trial. Persons 70 years or older without known AF but diagnosed with 1 or more of the following, hypertension, diabetes, heart failure, or prior stroke, were screened for inclusion. Four sites in Denmark recruited participants by letter between January 31, 2014, and May 17, 2016. The median (IQR) follow-up period was 65 (59-70) months. Data were analyzed from April 1 to May 31, 2022. ILR screening for AF and anticoagulation initiation if AF duration of 6 minutes or longer was detected (ILR group) vs usual care (control group). Adjudicated stroke, classified according to the modified Rankin Scale (mRS) using a score of 3 or more as a cutoff for severe (disabling or lethal) stroke, and according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification for ischemic strokes. A total of 6205 individuals were screened for inclusion, and 6004 were randomized and included in the analysis; 4503 participants (75%; mean [SD] age, 74.7 [4.1] years; 2375 male [52.7%]) were assigned to the control group and 1501 participants (25%; mean [SD] age, 74.7 [4.1] years; 792 male [52.8%]) were assigned to the ILR group. A total of 794 of 4503 participants (17.6%) in the control group had a history of prior stroke compared with 262 of 1501 participants (17.5%) in the ILR group. During follow-up, AF was diagnosed in 1027 participants (control group, 550 [12%] vs ILR group, 477 [32%]), and anticoagulation was initiated in 89% of these (910). A total of 315 participants (5.2%) had a stroke (control group, 249 [5.5%] vs ILR group, 66 [4.4%]), and the median (IQR) mRS score was 2 (1-3) with no difference across the groups. A total of 272 participants (4.5%) had ischemic stroke (control group, 217 [4.8%] vs ILR group, 55 [3.7%]), and 123 (2.0%) had severe stroke (control group, 100 [2.2%] vs ILR group, 23 [1.5%]), and the hazard ratios comparing the control and ILR groups were 0.76 (95% CI, 0.57-1.03; P = .07) and 0.69 (95% CI, 0.44-1.09; P = .11), respectively. For participants without prior stroke, the hazard ratios were 0.68 (95% CI, 0.48-0.97; P = .04) and 0.54 (95% CI, 0.30-0.97; P = .04), respectively. This post hoc analysis of the LOOP randomized clinical trial found that ILR screening for AF did not result in a significant decrease in ischemic or severe strokes compared with usual care. Exploratory subgroup analyses indicated a possible reduction of these outcomes among participants without prior stroke. ClinicalTrials.gov Identifier: NCT02036450.

Opportunistic screening for atrial fibrillation in hypertensive patients using a mobile application (prospective study of 160 cases)

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia,affecting between 1-4% of the general population and responsible for 10-20% of strokes. New technologies are now available for screening for AF,but their implementation in real clinical settings has not yet been fully investigated. Purpose -evaluate the electrocardiogram recordings on smartphones intended for screening for AF using the KardiaMobile device, with a dedicated mobile application. - Highlight the prevalence of AF in a moroccan hypertensive population -Evaluate the effectiveness of computerized screening for AF in therapeutic management Methods Prospective screening for AF in patients aged 55 or over,known to be hypertensive for at least 5 years, was performed at the cardiology consultation services between June 2019-July 2020.A single lead ECG was acquired by placing the fingers of each hand on the electrodesThe diagnosis of the Kardia app was assessed by the consultation cardiologist,and a baseline ECG was performed for each suspected arrhythmia.CHA2DS2-VASc score was collected from each patient. Results A total of 160 ECGs were performed.The diagnosis of the Kardia app was provided in 93% of cases.A heart rhythm described as normal was detected in 120 consultants,AFwas suspected in 8.1% of the patients described by the device as ‘possible AF’,and confirmed by a baseline ECG in 7.5% of the patients screened. Anti-coagulation was started in 6.2% of patients. Conclusion Mobile Device for screening for atrial fibrillation in a population at risk is a promising, inexpensive tool with significant prognostic benefit for the prevention of cardiovascular complications The Kardia app is able to quickly filter and detect atial fibrillation with high sensitivity and specificity.

Challenges in the Management of Atrial Fibrillation With Subclinical Hyperthyroidism.

Subclinical thyroid disorders have a high prevalence among older individuals and women. Subclinical hypothyroidism is diagnosed by elevated serum levels of thyroid-stimulating hormone (TSH) with thyroxine levels within the reference range, and subclinical hyperthyroidism is diagnosed by low TSH in conjunction with thyroxine and triiodothyronine levels within reference ranges. Atrial fibrillation is the most commonly diagnosed cardiac arrhythmia and has been associated with an increased risk of mortality, heart failure, stroke, and depression. Mechanistic data from animal and human physiology studies as well as observational data in humans support an association of subclinical hyperthyroidism with atrial fibrillation. Guidelines recommend the measurement of TSH in the evaluation of new-onset atrial fibrillation. All patients with overt hyperthyroidism should be treated, and treatment of subclinical hyperthyroidism should be considered in patients older than 65 years with TSH < 0.4 mlU/L, or in younger patients with TSH < 0.1 mlU/L. Guidelines also recommend screening for AF in patients with known hyperthyroidism. Wearable devices that measure the heart electrical activity continuously may be a novel strategy to detect atrial fibrillation in patients at risk. In this review, we explore the interplay between thyroid hormones and atrial fibrillation, management controversies in subclinical hyperthyroidism, and potential strategies to improve the management of atrial fibrillation in patients with subclinical hyperthyroidism.

Atrial Fibrillation and Ischemic Stroke: A Clinical Review.

Atrial fibrillation (AF) is an important risk factor for ischemic stroke resulting in a fivefold increased stroke risk and a twofold increased mortality. Our understanding of stroke mechanisms in AF has evolved since the concept of atrial cardiopathy was introduced as an underlying pathological change, with both AF and thromboembolism being common manifestations and outcomes. Despite the strong association with stroke, there is no evidence that screening for AF in asymptomatic patients improves clinical outcomes; however, there is strong evidence that patients with embolic stroke of undetermined source may require long-term monitoring to detect silent or paroxysmal AF. Stroke prevention in patients at risk, assessed by the CHA2DS2-VASc score, was traditionally achieved with warfarin; however, direct oral anticoagulants have solidified their role as safe and effective alternatives. Additionally, left atrial appendage exclusion has emerged as a viable option in patients intolerant of anticoagulation. When patients with AF have an acute stroke, the timing of initiation or resumption of anticoagulation for secondary stroke prevention has to be balanced against the risk of hemorrhagic conversion. Multiple randomized clinical trials are currently underway to determine the best timing for administration of anticoagulants following acute ischemic stroke.

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

Atrial 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. To investigate the yield of opportunistic screening for AF in usual primary care using a single-lead ECG device. A clustered, randomised controlled trial among patients aged ≥65 years with no recorded AF status in the Netherlands from October 2014 to March 2016. Fifteen 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. In 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. Opportunistic 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 ≥65 years in the community than usual care. For higher participation rates in future studies, more rigorous screening methods are needed.

Development and Validation of a Prediction Model for Atrial Fibrillation Using Electronic Health Records.

This study sought to determine whether the risk of atrial fibrillation AF can be estimated accurately byusing routinely ascertained features in the electronic health record (EHR) and whether AF risk is associated withstroke. Early diagnosis of AF and treatment with anticoagulation may prevent strokes. Using a multi-institutional EHR, this study identified 412,085 individuals 45 to 95 years of age without prevalent AF between 2000 and 2014. A prediction model was derived and validated for 5-year AF risk by using split-sample validation and model performance was compared with other methods of AF risk assessment. Within 5 years, 14,334 individuals developed AF. In the derivation sample (7,216 AF events of 206,042 total), the optimal risk model included sex, age, race, smoking, height, weight, diastolic blood pressure, hypertension, hyperlipidemia, heart failure, coronary heart disease, valvular disease, prior stroke, peripheral arterial disease, chronic kidney disease, hypothyroidism, and quadratic terms for height, weight, and age. In the validation sample (7,118 AF events of 206,043 total) the AF risk model demonstrated good discrimination (C-statistic: 0.777; 95% confidence interval [CI:] 0.771 to 0.783) and calibration (0.99; 95%CI: 0.96 to 1.01). Model discrimination and calibration were superior to CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology AF) (C-statistic: 0.753; 95%CI: 0.747 to 0.759; calibration slope: 0.72; 95%CI: 0.71 to 0.74), C2HEST (Coronary artery disease / chronic obstructive pulmonary disease; Hypertension; Elderly [age ≥75 years]; Systolic heart failure; Thyroid disease [hyperthyroidism]) (C-statistic: 0.754; 95%CI: 0.747 to 0.762; calibration slope: 0.44; 95%CI: 0.43 to 0.45), and CHA2DS2-VASc (Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, Prior stroke, transient ischemic attack [TIA], or thromboembolism, Vascular disease, Age 65-74 years, Sex category [female]) scores (C-statistic: 0.702; 95%CI: 0.693 to 0.710; calibration slope: 0.37; 95%CI: 0.36 to 0.38). AF risk discriminated incident stroke (n=4,814; C-statistic: 0.684; 95%CI: 0.677 to 0.692) and stroke within 90days of incident AF (n=327; C-statistic: 0.789; 95%CI: 0.764 to 0.814). A model developed from a real-world EHR database predicted AF accurately and stratified stroke risk. Incorporating AF prediction into EHRs may enable risk-guided screening for AF.

P3769Rapid referral to a one-stop AF clinic following possible AF detection by community pharmacists leads to early diagnosis and appropriate anticoagulant treatment

Abstract Background Atrial fibrillation is the most common cardiac arrhythmia globally, responsible for one third of ischaemic strokes, often resulting in death or incapacity. This condition, frequently asymptomatic is estimated to be up to 50% undiagnosed. Reducing this risk with appropriate detection and management strategies offers substantial economic and patient benefits. Community pharmacists have been shown to be an accessible healthcare professional capable of detecting atrial fibrillation. Concerns raised utilising community pharmacists is the additional workload for primary care physicians, and lack of a clear pathway to ensure patients are adequate followed with assurance of initiation of anticoagulation therapy. Purpose To assess the feasibility of screening by community pharmacists with onward referral to an innovative one-stop AF clinic to enable identification of new cases of AF and subsequent initiation of anticoagulation within 2 weeks. Methods 21 pharmacies were recruited and trained on pathophysiology of AF and demonstration of pulse taking using pulse check and Kardia mobile device. Any person walking into a community pharmacy aged ≥65 years was offered a free pulse check. For any irregularity detected, individualised counselling was offered with a referral made to a one-stop AF clinic for confirmation and initiation of anticoagulation. Written patient consent was obtained. Results 672 people were recruited with an average age of 69±3.5 years and 58% female (n=389). There was a history of hypertension in 618 (92%) and diabetes in 242 (36%), the most common co-morbidities. 45 people were referred following an irregular pulse or abnormal ECG rhythm strip, of whom 11 (1.6% of total population) had a confirmed AF diagnosis within 30 day follow up. An additional 8 cases with known AF not receiving anticoagulation termed (actionable AF) were also referred. All 19 cases of new or untreated AF were prescribed anticoagulation by the one stop clinic in accordance with guideline recommendations Conclusions ESC guidance recommends opportunistic screening for AF by pulse taking or ECG rhythm strip in patients ≥65 years of age. The 1.6% incidence of new AF was in accordance with meta-analyses identifying 1.4% of those aged ≥65 on a single time point check for presence of AF. Our model utilises the un-tapped skills of community pharmacy to deliver pulse checks of ECG rhythm recordings in an accessible primary care location with a clear referral pathway that is effective in early review and ensuring suitable patients receive anticoagulation. The innovative pathway could provide remote triage at scale and help address the missing people with undiagnosed and actionable AF by opening new channels for identification by healthcare professionals managing long term conditions who like pharmacists have not been considered suitable healthcare professionals due to lack of an established pathway for confirming the potential diagnosis of AF. Acknowledgement/Funding NHS England Test Bed Programme

P6135Improving detection of AF: insights from real world screening programme

Abstract Background AF related stroke places a significant burden on individuals, carers and health and social care systems. The observed prevalence of AF in populations is often lower than expected and this results in high rates of AF diagnosis at the time of the stroke event. Opportunistic screening for AF in at risk populations is recommended by ESC, however, is often missed due to time constraints and lack of expertise. Technological advancements such as m-health ECG monitors can aid in the diagnosis of AF with improvements in timely risk assessment and initiation of protective anticoagulation. Purpose The purpose of this study was to determine whether introduction of a suite of m-health tools including electronic patient record based tools and smart phone based ECG recording could improve the rates of AF detection and subsequently reduce the rate of AF related strokes. Methods The study was conducted in a city region with a population of around 300 000, served by 48 primary care practices. The project involved a three staged approach; education and support for primary care staff, creating an “at-risk” register on primary care electronic patient record for those over 60 or with relevant co-morbidities associated with electronic prompts for screening and a standardized assessment template and the roll-out of smart phone based single-lead ECG monitors to facilitate rhythm checks. The population was followed over a 4 year period to monitor rates of AF diagnosis, anticoagulation and stroke rates. Results The study population were male (53%), aged between 30–39 (22.4%) and were of white ethnicity (40%). At baseline, in 2014, the prevalence of AF was 0.89% (2492 individuals). By 2018, this had increased to 1.1% (3328 individuals) with on average 40 new diagnoses of AF compared to 26 in the baseline period (see figure).Anticoagulation prescription within 30 days of diagnosis increased from 29.80% to 50.00% whilst prescription of antiplatelet monotherapy within same time period decreased from 12.73% to 6.4%. This was also associated with a reduction in the proportion of strokes seen in the population secondary to AF with 35% (n=143) of strokes secondary to AF in 2014 and 25% (n=127) secondary to AF in 2017. Conclusion The study found that implementation of a screening programme across a wide range of primary care practices led to an improvement in AF diagnosis, management and timeliness of care. This highlights the benefit of using simple methods such as GP educations in conjunction with new technology device to detect AF more effectively and subsequently treat in an appropriate and time-effective fashion. In our population this appears to be associated with real reductions in AF related strokes Acknowledgement/Funding CLAHRC NWL, NHS Hounslow CCG, Pfizer