By Angela Gonzalez
In the quest to reduce the number of atrial fibrillation (AF) related strokes, which account for a third of all ischaemic strokes, there has been a greater interest in recent years in the need to identify unknown atrial fibrillation in the general population and particularly in the elderly, through opportunistic screening. Cardiac Rhythm News summarises key recently released recommendations and initiatives and speaks to leaders in the field Ben Freedman (Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, Australia) and Jeff Healey (Population Health Research Institute, McMaster University, Hamilton, Canada).
The World Heart Organization (WHO) estimates that between 1990 and 2013, the overall number of AF cases diagnosed globally increased from below 7 million to just over 11 million. The WHO states that these findings are “likely to underestimate the true scale of AF because of the large number of people who do not know they have the condition” and that the morbidity burden associated with AF, as measured by disability-adjusted life years, also continues to grow.
In its “Global roadmap to reducing premature cardiovascular disease mortality caused by AF”, launched in September 2016, the WHO highlighted that the lack of routinely palpated pulse checks in ≥65 year olds is a key component in the global care gap of AF management. It proposed the training of community health workers or pharmacists to screen for possible AF with pulse-checking in non-clinic settings and the education of this population to self-screen with pulse checks as potential solutions to overcome this issue.
In 2012, the European Society of Cardiology (ESC) included a class IB recommendation for opportunistic screening for AF in patients ≥65 years of age using pulse-taking followed by and ECG in its guidelines for the management of AF. This recommendation was again included in the 2016 guidelines with the addition that opportunistic screening can also be performed with an electrocardiogram (ECG) rhythm strip.
A growing body of evidence has supported this recommendation. Amongst relevant studies, a systematic review of clinical trials (Lowres N et al. Thromb Haemost 2013;110:213–222), which included 122,571 participants, found that screening or case finding in either the clinic or community, using either short-term ECG or pulse palpitation (followed by ECG in those with irregular pulse) will detect AF in 1.4% of patients on a single screening in those aged at least 65 years. In a viewpoint article Freedman and Nicole Lowres (University of Sydney, Sydney, Australia) published in JAMA in November 2015, they write that the strategy of screening people 65 years or older is “reasonable”, because the incidence of AF and the likelihood of stroke are greater in this age group.
The importance of opportunistic screening for unknown AF
Speaking on the importance of screening and treatment for unknown AF, Freedman, who is co-founder of the AF Screen International Collaboration—a group that was created over a year ago with the aim of promoting discussion and research about screening for unknown or undertreated AF as a way to reduce stroke and death—told Cardiac Rhythm News that opportunistic screening is “attacking the one in 10 strokes” that occurs as a result of AF that is not known until the time a stroke occurs. “Stroke is a very poor early sign of AF and if we want to prevent strokes we need to look for AF first and treat it adequately,” he noted. In a research review about stroke prevention in AF, recently published (The Lancet 2016;388:806‒17) by Freedman and others, the authors noted that findings from a Swedish registry of over 94,000 ischaemic strokes suggested that of all patients with ischaemic stroke, 20% had known but untreated or inadequately treated AF and 9% had previously unknown AF. “In these patients, stroke could have been prevented by either treatment with an oral anticoagulant according to current guidelines or by screening for AF,” Freedman et al noted. An accompanying editorial titled “Atrial fibrillation and stroke: unrecognised and undertreated” also highlighted the importance of opportunistic screening for AF. The editorial asks: “When did you or your primary care physician last palpate your wrist to check for a regular heart rate? This simple action, followed by an electrocardiogram if the heart rate is irregular, might be crucial in preventing death and disability from ischaemic stroke, heart failure or myocardial infarction”.
Jeff Healey, who is also a member of the Steering Committee of the AF Screen International Collaboration, told Cardiac Rhythm News that opportunistic screening for AF has many of the attributes that the WHO Wilson and Jungner criteria for systematic screening have proposed for ideal screening programmes, such as “being able to detect an asymptomatic form of the disease and being able to deliver highly-effective therapy to prevent stroke.” However, he noted that there is no guideline to recommend opportunistic or population-based screening for AF in Canada or the USA at the moment. This may be due to the fact that AF screening still encounters big challenges, amongst which, Healey commented, are difficulties engaging stakeholders for implementation of programmes into clinical practice. Additionally, there are challenges translating screen-detected AF into delivery of oral anticoagulant therapy in appropriate patients and also demonstrating its cost-effectiveness. “Many groups are looking to conduct large randomised trials that could directly demonstrate that AF screening prevents stroke,” he noted. “At the moment, the idea of a best strategy for AF screening is not known; I believe a best approach to AF screening will likely be country- or region-specific.”
In the viewpoint published in JAMA, Freedman and Lowres comment that “before recommending widespread screening for unknown AF, it is important to understand the prognosis of individuals detected”. Although data are limited, Freedman and Lowres note, results from the Mayo Clinic study in Olmstead County (Tsang et al, Can J Cardiol 2011;27(5):S122) and a UK study of 5,555 patients (Martinez et al, Thromb Haemost 2014;112(2):276‒286) indicate that incidentally detected AF that may be identified through a screening programme is “not benign, appears to respond to anticoagulant treatment with reduction of both stroke and death, and therefore warrants consideration of screening to detect the arrhythmia before stroke has occurred,” the authors state.
The role of community pharmacies in opportunistic screening of unknown AF
The role of community pharmacies in detecting unknown AF in the elderly has been explored in different country-specific studies. Freedman, who led SEARCH AF, a study of 1,000 pharmacy customers aged ≥65 years in Sydney, Australia, told Cardiac Rhythm News that implementing opportunistic screening in community pharmacies is relevant as older people, who are likely to have unknown AF, visit pharmacies frequently.
In SEARCH AF, newly identified AF was found in 1.5% of participants screened with pulse checks and iECG recordings using a handheld iPhone-based-lead-I ECG with the AliveCor Heart Monitor in 10 pharmacies. All patients had high stroke risk and were guideline-eligible for consideration of oral anticoagulants. The patients found with AF were referred to their GPs for review and management. This study concluded that iECG screening in pharmacies is a strategy that could “potentially reduce the high cost and societal burden of stroke and systemic thromboembolism”.
In Canada, the PIAFF-Pharmacy (Program for identification of “actionable” atrial fibrillation) study, conducted by the Canadian Stroke Prevention Intervention Network (C-SPIN) in 30 pharmacies and led by Jeff Healey, found “actionable” AF (actionable AF was defined as unrecognised or undertreated) was prevalent in 2.5% of 1,145 participants (≥65 years old) screened for AF using a single-lead handheld ECG device. Of these, 96% were newly diagnosed with AF, most of them with a CHA2DS2-VASc score >2. Patients were also screened for additional stroke risk factors such as hypertension and diabetes. Blood pressure >140/90 was found in 54.9% of participants and 44.4% were found to be at high risk of diabetes. At three months, 17% of participants were started on oral anticoagulation, 50% had improved blood pressure and 71% had confirmatory diabetes testing. Healey highlighted that the combined approach of this strategy helped to reduce the cost of delivering the screening programme. Results of this study will be published soon, Healey noted.
Sotiris Antoniou (consultant pharmacist at Barts Health NHS Trust, Barts Heart Centre, London, UK), chair of the International Pharmacists and Anticoagulation Care Task force (iPAC), told Cardiac Rhythm News that a community pharmacy initiative, similar to the one implemented in Australia with the SEARCH AF study, will look at recruiting approximately 10,000 participants in pharmacies in London. Freedman, who is an investigator in this study, said that the initiative will particularly explore pathways to facilitate communication between pharmacists and consultants for prescription of medication once the patient has been diagnosed with AF.
AF Association and Arrhythmia Alliance—patient groups dedicated to raise AF awareness through pulse checks
The UK-born patient groups, AF Association and Arrhythmia Alliance, have played a major role raising awareness and educating the general population around the world on the importance of pulse checks to detect AF through the “Know your pulse” campaign. Under the leadership of Trudie Lobban (founder and trustee of Arrhythmia Alliance/founder and CEO of AF Association), these patient groups have developed educational materials available to the general public and run pulse check events at schools, government offices, community centres, etc, throughout the year, engaging the general public, healthcare professionals and political bodies. The “Know your pulse” campaign message is reinforced during the Heart Rhythm Week in June each year and the AF Aware Week in November each year.
In 2016, Arrhythmia Alliance published the results of nearly 4,000 patients regarding routine screening for AF. Amongst key results, the survey found that 30% of those diagnosed with AF were under 60 years of age, 41% were ≥61 years old and 29% were ≥71 years old. Forty three per cent of the patients received screening following symptoms and 7% had no symptoms at all.
AF Screen International Collaboration—a global initiative dedicated to reduce stroke and death
With the aim of promoting the discussion and research about screening for unknown or undertreated atrial fibrillation as a way to reduce stroke and death, a group of atrial fibrillation experts formed the AF Screen International Collaboration at the ESC Congress in 2015. The group is led by steering committee members: John Camm (St George’s University of London, UK), Ben Freedman (Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, Australia), Jeff Healey (Population Health Research Institute, McMaster University, Hamilton, Canada), Hugh Calkins (Johns Hopkins Hospital, Baltimore, USA), Marten Rosenqvist (Karolinska Institutet, Stockholm, Sweden) and Ji-Guang Wang (Shanghai Institute of Hypertension, Shanghai, China).
Currently, the Collaboration has over 100 members including cardiologists, cardiac electrophysiologists, neurologists, geriatricians, epidemiologists, health economists, general and primary care physicians, nurses, pharmacists, physiotherapists, and patient advocates from 31 countries.
Healey told Cardiac Rhythm News that one of the key goals of this group was “to help streamline terminology such as screen-detected AF and device-detected atrial high-rate episodes.”
The Collaboration is also partnering with cardiology societies to run joint sessions at their symposia. In 2016, joint sessions on AF screening were held at the ESC Congress (27‒31 August, Rome, Italy), Heart Rhythm Congress (9‒12 October, Birmingham, UK) and the American Heart Association (AHA) Scientific Sessions (12–16 November, New Orleans, USA).
Freedman told Cardiac Rhythm News that they will release a consensus document on screening for AF in the coming months.