Screening For Asymptomatic Atrial Fibrillation Research Articles

Epidemiology and comprehensive economic impact of atrial fibrillation and associated stroke in Slovakia.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is also a major risk factor for ischemic stroke. The main objective of our study was to identify direct and indirect costs of AF and AF-related stroke in Slovakia. We conducted a retrospective population-based study of AF and stroke related costs both from the third-party healthcare payers and societal perspective. The prevalence and incidence of AF and stroke were determined from central government run healthcare database. Further we estimated both indirect and direct costs of AF and stroke. All costs and healthcare resources were assessed from 2015 through 2019 and were expressed in the respective year. Over the 5-year study period, the prevalence of AF increased by 26% to a total of 149,198 AF cases in 2019, with an estimated total annual economic burden of €66,242,359. Direct medical costs accounted for 94% of the total cost of AF. The total cost of treating patients with stroke in 2019 was estimated at €89,505,669. As a result, the medical costs of stroke that develops as a complication of AF have been estimated to be €25,734,080 in 2019. Our study shows a substantial economic burden of AF and AF-related stroke in Slovakia. In view of the above, both screening for asymptomatic AF in high-risk populations and effective early management of AF with a focused on thromboprophylaxis rhythm control should be implemented.

Возможности скрининга бессимптомной фибрилляции предсердий в клинической практике

Возможности скрининга бессимптомной фибрилляции предсердий в клинической практике

Serial 7-Day Electrocardiogram PatchScreening for AF inHigh-Risk Older Women by the CHARGE-AF Score.

Asymptomatic atrial fibrillation (AF) is associated with an increased risk of stroke. The yield of serial electrocardiographic (ECG) screening for AF is unknown. The aim of this study was to determine the frequency of AF detected by serial, 7-day ECG patch screenings in older women identified as having an elevated risk of AF according to the CHARGE (Cohorts for Heart and Aging Research in Genomic Epidemiology)-AF clinical prediction score. Postmenopausal women with a 5-year predicted risk of new-onset AF≥5% according to CHARGE-AF were recruited from the ongoing WHISH (Women's Health Initiative Strong and Healthy) randomized trial of a physical activity intervention. Participants with AF at baseline by self-report or medical records review were excluded. Screening with 7-day ECG patch monitors was performed at baseline, 6months, and 12months from study enrollment. On baseline monitoring, 2.5% of the cohort had AF detected, increasing to 3.7% by 6months and 4.9% cumulatively by 12months. Yield of patch screening was higher among participants with a higher (≥10%) CHARGE-AF score: 4.2% had AF detected at baseline, 5.9% at 6months, and 7.2% at 12months. Most participants with patch-identified AF never had a clinical diagnosis of AF (36 of 46 [78%]). Older women with an elevated CHARGE-AF score had a high prevalence of AF on 7-day ECG patch screening. Serial screening over 12months substantially increased the detection of AF. These data can be useful in helping identify high-risk participants for enrollment in future studies of the management of asymptomatic AF.(Women'sHealth Initiative Silent Atrial Fibrillation Recording Study [WHISH STAR]; NCT05366803.).

One size does not fit all – a realist review of screening for asymptomatic atrial fibrillation in Indigenous communities in Australia, Canada, New Zealand and United States

Abstract Background/Introduction Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and it is increasing in prevalence and incidence globally. True prevalence is underestimated because silent/asymptomatic AF is frequent and under-detected, but can cause stroke. Guidelines recommend opportunistic screening for AF in patients aged ≥65 years old. A growing body of evidence from hospital and community-based studies in Australia, New Zealand, Canada and United States indicates this age limit is lower for Indigenous people. Screening for AF meets the World Health Organisation (WHO) criteria for successful routine screening, yet little is known about successful implementation of AF screening in Indigenous communities in developed countries. Purpose The aim of this study is to use a realist approach to identify what works, how, for whom and under what circumstances for AF screening of Indigenous communities in Australia, Canada, New Zealand and United States. Methods In the realist review, eight databases were searched for studies targeted at AF screening in Indigenous communities. Realist analysis was used to identify context-mechanism-outcome configurations across 11 included records (reporting on 5 studies). Snowball referencing and grey literature were used to iteratively incorporate evidence to enhance the refined programme theory that was the product of the realist analysis. Results The realist review included studies using multiple screening strategies such as using tools to increase screening, using different screening environments and training screeners to provide culturally centred care. The realist analysis identified a number of mechanisms that can improve AF screening in Indigenous communities. The contextual factors enabling AF screening programs in Indigenous communities include wider community engagement, opportunistic non-clinical settings, using portable and easy to use devices, increasing knowledge, motivation and confidence in screening amongst Indigenous healthcare workers as well as improving follow-up protocols for abnormal results tailored to screen setting. Barriers to effective AF screening include time-poor working environments, conflicting cultural issues, navigating communication of abnormal results and logistical issues with device use (Figure 1). Conclusion(s) Since the life-course risk for AF in Indigenous population is different, a modified screening strategy needs to be put in place. This realist review provides lessons learned for successful implementation of AF screening programs for Indigenous communities. In order to tackle the gap in cardiovascular burden in Indigenous people, this study calls for action to develop AF screening guidelines for Indigenous populations and provides a guide for policy makers about timely and effective AF screening programs for Indigenous communities. Funding Acknowledgement Type of funding sources: None.

Screening for atrial fibrillation: predicted sensitivity of short, intermittent electrocardiogram recordings in an asymptomatic at-risk population.

AimsScreening for asymptomatic atrial fibrillation (AF) could prevent strokes and save lives, but the AF burden of those detected can impact prognosis. New technologies enable continuous monitoring or intermittent electrocardiogram (ECG) snapshots, however, the relationship between AF detection rates and the burden of AF found with intermittent strategies is unknown. We simulated the likelihood of detecting AF using real-world 2-week continuous ECG recordings and developed a generalizable model for AF detection strategies.Methods and resultsFrom 1738 asymptomatic screened individuals, ECG data of 69 individuals (mean age 76.3, median burden 1.9%) with new AF found during 14 days continuous monitoring were used to simulate 30 seconds ECG snapshots one to four times daily for 14 days. Based on this simulation, 35–66% of individuals with AF would be detected using intermittent screening. Twice-daily snapshots for 2 weeks missed 48% of those detected by continuous monitoring, but mean burden was 0.68% vs. 4% in those detected (P < 0.001). In a cohort of 6235 patients (mean age 69.2, median burden 4.6%) with paroxysmal AF during clinically indicated monitoring, simulated detection rates were 53–76%. The Markovian model of AF detection using mean episode duration and mean burden simulated actual AF detection with ≤9% error across the range of screening frequencies and durations.ConclusionUsing twice-daily ECG snapshots over 2 weeks would detect only half of individuals discovered to have AF by continuous recordings, but AF burden of those missed was low. A model predicting AF detection, validated using real-world data, could assist development of optimized AF screening programmes.

Identification of atrial fibrillation in secondary care diabetes and vascular clinics: a pilot study.

Aim: To determine the feasibility and utility of the AliveCor® handheld ECG device in screening for asymptomatic atrial fibrillation in high-risk patients attending secondary care clinics. Materials & methods: Patients were recruited from diabetes and vascular outpatient clinics, and the AliveCor device used to store a 30-second ECG recording. Clinical risk stratification systems (CHAD2S2-VASc and HAS-BLED) assessed individual suitability for oral anticoagulation. Results: Atrial fibrillation was detected in 2 of 149 patients (1.3%), with CHA2DS2-VASc-derived annual stroke risk of 4%. Given low bleeding susceptibility (HAS-BLED), oral anticoagulation was strongly indicated. Conclusion: AliveCor technology offers a simple approach to retrieve large volumes of ECG data. A follow-up study with a larger cohort would reinforce the clinical utility of screening this high-risk population.

Diagnostic accuracy of apex-pulse deficit for detecting atrial fibrillation

Background: Screening for asymptomatic atrial fibrillation (AF) can identify patients at risk of stroke and help initiate treatment. Apex-pulse deficit, the difference between apex beat rate and peripheral pulse rate, has been described as a clinical sign to identify AF. However, the accuracy of this measure to identify AF has not been studied before. Aims: The primary aim of this study was to determine the sensitivity and specificity of apex-pulse deficit more than 10, measured over 1 min, to identify AF using 12-lead electrocardiogram (ECG) as the gold standard. Methods: This was a prospective cross-sectional study. Subjects were those above 30 years of age with known AF (cases) or not in AF (controls). Apex-pulse deficit was measured in each of them and correlated with rhythm detected in 12-lead ECG. Results: A total of 70 patients were studied, 35 cases and 35 controls. Apex-pulse deficit was significantly larger for cases as compared to controls and was a good discriminant to identify AF. Receiver operating characteristic curve analysis showed an area under the curve of 0.86. With a cutoff of 10, sensitivity and specificity to identify AF were 62.8% and 85.7%, respectively. Using a cutoff of 5 increased the sensitivity to 80%. Counting over 30 s was significantly less accurate than counting over one full minute. Conclusion: Apex-pulse deficit is a low-cost method to identify AF and may be useful for screening. A cutoff of 5 may enhance the sensitivity of measurement as compared to the traditional cutoff of 10.

Automatic Blood Pressure Monitor Accurately Detects AF

Automatic blood pressure screening with a blood pressure monitor can accurately detect new cases of atrial fibrillation (AF) among older populations, according to a recent U.S. study. Long-term residents of skilled nursing facilities frequently have multiple risk factors for strokes due to AF, and studies have shown that screening for AF may allow residents the opportunity to begin treatment that lowers their risk for stroke. The American Heart Association and the British National Institute for Health and Care Excellence (NICE) both recommend AF screening for residents 65 years and older in primary care clinics. NICE specifically recommends the Microlife WatchBP Home A (BPM-AF), an automatic blood pressure monitor that can detect AF when set to a triple-reading mode. Results from past studies have shown that the monitor has a sensitivity of 95% and specificity of 90% for detecting AF. In 2016 Joseph Wiesel, MD, and Thomas J. Salomone, DrNP, FNP, conducted a pilot program to assess the efficacy of the BPM-AF monitor for AF screening among long-term residents at an SNF in the northeastern United States. Their results, published in the American Journal of Cardiology [July 24, 2017; doi: 10.1016/j.amjcard.2017.07.016], showed that the BPM-AF identified 9 residents with possible AF out of 101 residents screened. In five of those residents the AF was confirmed by a 12-lead electrocardiogram (ECG), and in two of the remaining four it was confirmed using an immediate 30-second single-lead ECG. Overall, 113 residents of extended care units who were 65 and older were eligible to participate, and a total of 101 residents were screened. The average age of the screened residents was 77.7 years, and men made up 52% of the cohort. Residents with dementia, using a ventilator, or housed in short-term rehabilitation were excluded, as were residents with previously diagnosed AF, those who had a pacemaker or a defibrillator, and those who were unavailable or uncooperative. The investigators used the BPM-AF in the automatic three-sequential-reading mode, as recommended for AF screening and maximum blood pressure accuracy. If the BPM-AF detected possible AF, the nurse on the unit would request a standard 12-lead ECG as per routine practice. All 12-lead ECGs in the study were interpreted by a board-certified cardiologist who provided routine ECG readings for the facility. When the investigators could not perform a 12-lead ECGs until several days after an abnormal BPM-AF reading, they immediately collected a backup with a 30-second single-lead ECG handheld device. In the cases where the resident’s delayed 12-lead ECG did not show AF, a board-certified cardiologist interpreted the 30-second single-lead ECG result. The residents with AF confirmed by either the 12-lead ECG or the immediate single-lead ECG were considered to have AF. With one screening BMP-AF reading and a routine confirmatory 12-lead ECG, the incidence of new AF was 4.9%. Including the residents whose AF was confirmed by an immediate 30-second single-channel ECG, the incidence rate increased to 6.9%. The false-positive rate was 2%. The investigators noted that their AF detection rates were significantly higher than the 1.61% rate obtained via systematic screening using one ECG in participants 65 and older from a general outpatient medical population (BMJ 2007;335:383–388) and the 1.2% incidence rate recorded for ECG screening among 75-year-old community residents (Circulation 2013;127:930–937). “Residents of skilled nursing facilities may be at particularly high risk of undiagnosed AF and would benefit from routine screening for AF,” wrote Drs. Wiesel and Salomone. They also noted that “given the high prevalence of previously undiagnosed AF found in this study, expanding the criteria for AF screening to include younger skilled nursing facility residents may be appropriate.” Braxton Poe is a freelance writer in the Philadelphia area. We certainly have the technology to do widespread screening for asymptomatic atrial fibrillation in our nursing home residents. Considering the prevalence of risk factors for stroke that would make them good candidates for anticoagulation, this may become the standard of care. However, we need to consider burdens vs. benefits, and allow our patients or their decision-makers to make informed decisions about whether such screening is appropriate for an individual patient. If patients are at excessively high risk for bleeding or falls, or if they have substantially limited life expectancy, then perhaps it is of no benefit to know that they may be experiencing AF since anticoagulation would be relatively contraindicated. Antiarrhythmic medications could be considered for some. And for others, nonpharmacological interventions such as radiofrequency ablation might be considered. As long as we keep the individual patient’s goals of care and specific medical profile in mind, this technology has the potential to prevent many strokes. —Karl Steinberg, MD, CMD, HMDC Editor in Chief

Screening For Asymptomatic Atrial Fibrillation: Its Effectiveness And Cost-Effectiveness Of Repeated Ecg In Poland

Screening For Asymptomatic Atrial Fibrillation: Its Effectiveness And Cost-Effectiveness Of Repeated Ecg In Poland

Assessment of Remote Heart Rhythm Sampling Using the AliveCor Heart Monitor to Screen for Atrial Fibrillation: The REHEARSE-AF Study.

Asymptomatic atrial fibrillation (AF) is increasingly common in the aging population and implicated in many ischemic strokes. Earlier identification of AF with appropriate anticoagulation may decrease stroke morbidity and mortality. We conducted a randomized controlled trial of AF screening using an AliveCor Kardia monitor attached to a WiFi-enabled iPod to obtain ECGs (iECGs) in ambulatory patients. Patients ≥65 years of age with a CHADS-VASc score ≥2 free from AF were randomized to the iECG arm or routine care (RC). iECG participants acquired iECGs twice weekly over 12 months (plus additional iECGs if symptomatic) onto a secure study server with overread by an automated AF detection algorithm and by a cardiac physiologist and/or consultant cardiologist. Time to diagnosis of AF was the primary outcome measure. The overall cost of the devices, ECG interpretation, and patient management were captured and used to generate the cost per AF diagnosis in iECG patients. Clinical events and patient attitudes/experience were also evaluated. We studied 1001 patients (500 iECG, 501 RC) who were 72.6±5.4 years of age; 534 were female. Mean CHADS-VASc score was 3.0 (heart failure, 1.4%; hypertension, 54%; diabetes mellitus, 30%; prior stroke/transient ischemic attack, 6.5%; arterial disease, 15.9%; all CHADS-VASc risk factors were evenly distributed between groups). Nineteen patients in the iECG group were diagnosed with AF over the 12-month study period versus 5 in the RC arm (hazard ratio, 3.9; 95% confidence interval=1.4-10.4; P=0.007) at a cost per AF diagnosis of $10 780 (£8255). There was a similar number of stroke/transient ischemic attack/systemic embolic events (6 versus 10, iECG versus RC; hazard ratio=0.61; 95% confidence interval=0.22-1.69; P=0.34). The majority of iECG patients were satisfied with the device, finding it easy to use without restricting activities or causing anxiety. Screening with twice-weekly single-lead iECG with remote interpretation in ambulatory patients ≥65 years of age at increased risk of stroke is significantly more likely to identify incident AF than RC over a 12-month period. This approach is also highly acceptable to this group of patients, supporting further evaluation in an appropriately powered, event-driven clinical trial. URL: https://www.isrctn.com. Unique identifier: ISRCTN10709813.

Screening for Atrial Fibrillation in Patients ≥65 Years Using an Automatic Blood Pressure Monitor in a Skilled Nursing Facility

Early detection of asymptomatic atrial fibrillation (AF) provides an opportunity to treat patients to reduce their risk of stroke. Long-term residents of skilled nursing facilities frequently have multiple risk factors for strokes due to AF and may benefit from screening for AF. Patients in a skilled nursing facility 65 years and older, without a history of AF and without a pacemaker or defibrillator, were evaluated using a Microlife WatchBP Home A automatic blood pressure monitor that can detect AF when set to a triple reading mode. Those with readings positive for AF were evaluated with a standard 12-lead electrocardiogram (ECG) or a 30-second single-channel ECG to confirm the presence of AF. A total of 101 patients were screened with an average age of 78 years, and 48 (48%) were female. Nine automatic blood pressure monitor readings were positive for possible AF. Of those, 7 (6.9%, 95% confidence intervals 3.0% to 14.2%) had AF confirmed with ECG. Only 2 (2%, 95% confidence interval 0.3% to 7.7%) were false-positive readings. One-time screening for AF using an automatic blood pressure monitor in a skilled nursing facility resulted in a high number of patients with newly diagnosed AF.

Accurate, Automated Detection of Atrial Fibrillation in Ambulatory Recordings.

A highly accurate, automated algorithm would facilitate cost-effective screening for asymptomatic atrial fibrillation. This study analyzed a new algorithm and compared it to existing techniques. The incremental benefit of each step in refinement of the algorithm was measured, and the algorithm was compared to other methods using the Physionet atrial fibrillation and normal sinus rhythm databases. When analyzing segments of 21 RR intervals or less, the algorithm had a significantly higher area under the receiver operating characteristic curve (AUC) than the other algorithms tested. At analysis segment sizes of up to 101 RR intervals, the algorithm continued to have a higher AUC than any of the other methods tested, although the difference from the second best other algorithm was no longer significant, with an AUC of 0.9992 with a 95% confidence interval (CI) of 0.9986-0.9998, vs. 0.9986 (CI 0.9978-0.9994). With identical per-subject sensitivity, per-subject specificity of the current algorithm was superior to the other tested algorithms even at 101 RR intervals, with no false positives (CI 0.0-0.8%) vs. 5.3% false positives for the second best algorithm (CI 3.4-7.9%). The described algorithm shows great promise for automated screening for atrial fibrillation by reducing false positives requiring manual review, while maintaining high sensitivity.

Cost-effectiveness of mass screening for untreated atrial fibrillation using intermittent ECG recording.

The aim of this study was to estimate the cost-effectiveness of 2 weeks of intermittent screening for asymptomatic atrial fibrillation (AF) in 75/76-year-old individuals. The cost-effectiveness analysis of screening in 75-year-old individuals was based on a lifelong decision analytic Markov model. In this model, 1000 hypothetical individuals, who matched the population of the STROKESTOP study, were simulated. The population was analysed for different parameters such as prevalence, AF status, treatment with oral anticoagulation, stroke risk, utility, and costs. In the base-case scenario, screening of 1000 individuals resulted in 263 fewer patient-years with undetected AF. This implies eight fewer strokes, 11 more life-years, and 12 more quality-adjusted life years (QALYs) per 1000 screened individuals. The screening implies an incremental cost of €50 012, resulting in a cost of €4313 per gained QALY and €6583 per avoided stroke. With the use of a decision analytic simulation model, it has been shown that screening for asymptomatic AF in 75/76-year-old individuals is cost-effective.

Screening for Asymptomatic Atrial Fibrillation While Monitoring the Blood Pressure at Home: Trial of Regular Versus Irregular Pulse for Prevention of Stroke (TRIPPS 2.0)

Asymptomatic atrial fibrillation (AF) is a common cause of strokes. Physician screening for AF has been recommended. Home screening for AF may increase the likelihood of detecting asymptomatic AF in patients at risk for stroke because of AF. The aim of this study was to assess the feasibility and accuracy of screening for AF when taking home blood pressure (BP) measurements using an automatic AF-detecting BP monitor. Subjects aged >64 years or those with hypertension, diabetes, congestive heart failure, or previous stroke were enrolled by their primary physicians and given the AF-BP monitor and an electrocardiographic event monitor to use at home for 30 days. The AF-BP monitor reading was compared with the electrocardiographic reading to calculate the sensitivity and specificity of the device for detecting AF. A total of 160 subjects were enrolled, with 10 withdrawing, 1excluded, and 10 with no AF-BP monitor logs or electrocardiographic recordings. Of the 139 subjects included, 14 had known AF. There was a total of 3,316 days with AF-BP monitor readings and electrocardiographic readings. On the basis of the initial daily AF-BP monitor readings, the AF-BP monitor demonstrated sensitivity of 99.2% and specificity of 92.9% for detecting AF. Two subjects with no histories of AF had AF-BP monitor readings of AF that were confirmed by the electrocardiographic monitor. One of these subjects was started on warfarin. In conclusion, home screening for asymptomatic AF while taking BP measurements can be performed accurately. This can be used to detect new AF, allowing treatment with anticoagulation to reduce the future risk for stroke.

Short-term ECG for out of hospital detection of silent atrial fibrillation episodes

Objectives. We evaluated a short-term ECG, thumb ECG, for detection of asymptomatic atrial fibrillation (AF) episodes. The aim was to evaluate registration efficacy, sensitivity, specificity, quality and feasibility in patients with special emphasis on asymptomatic AF. Design. One hundred patients registered their cardiac rhythm with 12-lead ECG immediately followed by thumb ECG. The registrations were compared blindly. A second group of 12 patients, who had successfully undergone cardioversion, performed rhythm registration twice daily for 30 days. A third group of 606 individuals underwent an AF screening procedure. Results. Thumb ECG correctly diagnosed AF (sensitivity) in 96% and sinus rhythm (specificity) in 92% compared with 12-lead ECG. In the group of cardioverted patients, 466 registrations were validated: 95% had satisfactory quality for diagnosis: four patients experienced AF recurrence in which three were asymptomatic. In the third group 12 persons were diagnosed with AF, six of these had neither symptoms nor a history of AF. Conclusions. Short-term ECG is able to diagnose AF with a high sensitivity, specificity and simple application making detection of asymptomatic AF possible for screening purposes.