Diagnostic accuracy and yield of screening tests for atrial fibrillation in the family practice setting: a multicentre cohort study

Quinn, F. Russell; Gladstone, David J.; Ivers, Noah; Sandhu, Roopinder K.; Dolovich, Lisa; Ling, Andrea; Nakamya, Juliet; Ramasundarahettige, Chinthanie; Frydrych, Paul A.; Henein, Sam; Ng, Kelvin; Congdon, Valerie; Birtwhistle, Richard; Ward, Richard A.; Healey, Jeffrey S.

doi:10.9778/cmajo.20180001

Cited by 20 publications

(8 citation statements)

References 38 publications

(34 reference statements)

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“…CHA 2 DS 2 -VASc scores were available for 1,369 new AF cases, collected at the time of screening, from 18/19 studies [11–24,26–29]. As expected, mean CHA 2 DS 2 -VASc scores increased progressively with age, with step increases at ages 65 and 75 years (Table 2).…”

Section: Resultsmentioning

confidence: 69%

Estimated stroke risk, yield, and number needed to screen for atrial fibrillation detected through single time screening: a multicountry patient-level meta-analysis of 141,220 screened individuals

et al. 2019

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BackgroundThe precise age distribution and calculated stroke risk of screen-detected atrial fibrillation (AF) is not known. Therefore, it is not possible to determine the number needed to screen (NNS) to identify one treatable new AF case (NNS-Rx) (i.e., Class-1 oral anticoagulation [OAC] treatment recommendation) in each age stratum. If the NNS-Rx is known for each age stratum, precise cost-effectiveness and sensitivity simulations can be performed based on the age distribution of the population/region to be screened. Such calculations are required by national authorities and organisations responsible for health system budgets to determine the best age cutoffs for screening programs and decide whether programs of screening should be funded. Therefore, we aimed to determine the exact yield and calculated stroke-risk profile of screen-detected AF and NNS-Rx in 5-year age strata.Methods and findingsA systematic review of Medline, Pubmed, and Embase was performed (January 2007 to February 2018), and AF-SCREEN international collaboration members were contacted to identify additional studies. Twenty-four eligible studies were identified that performed a single time point screen for AF in a general ambulant population, including people ≥65 years. Authors from eligible studies were invited to collaborate and share patient-level data. Statistical analysis was performed using random effects logistic regression for AF detection rate, and Poisson regression modelling for CHA2DS2-VASc scores. Nineteen studies (14 countries from a mix of low- to middle- and high-income countries) collaborated, with 141,220 participants screened and 1,539 new AF cases. Pooled yield of screening was greater in males across all age strata. The age/sex-adjusted detection rate for screen-detected AF in ≥65-year-olds was 1.44% (95% CI, 1.13%–1.82%) and 0.41% (95% CI, 0.31%–0.53%) for <65-year-olds. New AF detection rate increased progressively with age from 0.34% (<60 years) to 2.73% (≥85 years). Neither the choice of screening methodology or device, the geographical region, nor the screening setting influenced the detection rate of AF. Mean CHA2DS2-VASc scores (n = 1,369) increased with age from 1.1 (<60 years) to 3.9 (≥85 years); 72% of ≥65 years had ≥1 additional stroke risk factor other than age/sex. All new AF ≥75 years and 66% between 65 and 74 years had a Class-1 OAC recommendation. The NNS-Rx is 83 for ≥65 years, 926 for 60–64 years; and 1,089 for <60 years. The main limitation of this study is there are insufficient data on sociodemographic variables of the populations and possible ascertainment biases to explain the variance in the samples.ConclusionsPeople with screen-detected AF are at elevated calculated stroke risk: above age 65, the majority have a Class-1 OAC recommendation for stroke prevention, and >70% have ≥1 additional stroke risk factor other than age/sex. Our data, based on the largest number of screen-detected AF collected to date, show the precise relationship between yield and estimated stroke risk profile with age, and str...

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Section: Resultsmentioning

confidence: 69%

Estimated stroke risk, yield, and number needed to screen for atrial fibrillation detected through single time screening: a multicountry patient-level meta-analysis of 141,220 screened individuals

et al. 2019

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“…Few studies have directly compared pulse palpation with the newly available digital technology for the detection of AF, despite pulse palpation being the recommended method for first-line detection of AF by NICE and charities such as the Arrhythmia Alliance [ 31 , 58 ]. Three studies reported that pulse palpation had much lower specificity than the newer technology [ 59 – 61 ]. Indirect comparisons reported in systematic reviews demonstrated that pulse palpation in six studies showed reasonable sensitivity (0.92 [0.85–0.96]) as a technique; however, specificity (0.82 [0.76–0.88]) was much lower compared with other methods [ 29 ].…”

Section: Discussionmentioning

confidence: 99%

“…The issue of using pulse palpation as a first step in the detection of AF is that an irregular pulse is an indicator not just of AF but also of many other conditions [ 29 ], and therefore, 70%–87% of all pulse irregularities will not be AF [ 66 ]. Consequently, mass screening using pulse palpation will lead to a high number of false positives and, to a lesser extent, false negatives when used solely as a screening test for AF [ 29 , 59 , 60 ]. For many patients, being told that they possibly had AF would likely cause undue worry and concern if not dealt with correctly by those doing the screening and would be particularly problematic if the patient was independently screening themselves.…”

Section: Discussionmentioning

confidence: 99%

Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study

et al. 2020

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Background Growing prevalence of atrial fibrillation (AF) in the ageing population and its associated life-changing health and resource implications have led to a need to improve its early detection. Primary care is an ideal place to screen for AF; however, this is limited by shortages in general practitioner (GP) resources. Recent increases in the number of clinical pharmacists within primary care makes them ideally placed to conduct AF screening. This study aimed to determine the feasibility of GP practice–based clinical pharmacists to screen the over-65s for AF, using digital technology and pulse palpation during the influenza vaccination season. Methods and findings Screening was conducted over two influenza vaccination seasons, 2017–2018 and 2018–2019, in four GP practices in Kent, United Kingdom. Pharmacists were trained by a cardiologist to pulse palpate, record, and interpret a single-lead ECG ( SL ECG). Eligible persons aged ≥65 years (y) attending an influenza vaccination clinic were offered a free heart rhythm check. Six hundred four participants were screened (median age 73 y, 42.7% male). Total prevalence of AF was 4.3%. All participants with AF qualified for anticoagulation and were more likely to be male (57.7%); be older; have an increased body mass index (BMI); and have a CHA 2 DS 2 -VASc (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes, previous Stroke, Vascular disease, Age 65–74 years, Sex category) score ≥ 3. The sensitivity and specificity of clinical pharmacists diagnosing AF using pulse palpation was 76.9% (95% confidence interval [CI] 56.4–91.0) and 92.2% (95% CI 89.7–94.3), respectively. This rose to 88.5% (95% CI 69.9–97.6) and 97.2% (95% CI 95.5–98.4) with an SL ECG. At follow-up, four participants (0.7%) were diagnosed with new AF and three (0.5%) were initiated on anticoagulation. Screening with SL ECG also helped identify new non-AF cardiovascular diagnoses, such as left ventricular hypertrophy, in 28 participants (4.6%). The screening strategy was cost-effective in 71.8% and 64.3% of the estimates for SL ECG or pulse palpation, respectively. Feedback from participants (422/604) was generally positive. Key limitations of the study were that the intervention did not reach individuals who did not attend the practice for an influenza vaccination and there was a limited representation of UK ethnic minority groups in the study cohort. Conclusions This study demonstrates that AF screening performed by GP practice–based pharmacists was feasible, economically viable, and positively endorsed by participants. Furthermore, diagnosis of AF by the clinical pharmacist using an SL ECG was more sensitive and more specific than the use of pulse palpation alone. Future research should explore the key barriers preventing th...

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“…It is worth noting that the aforementioned 2018 consultation did not take into account the latest FDAapproved mobile/wearable ECG sensors from AliveCor, Apple, Withings and others, which are available for anyone to buy (and use on their own), e.g., on Amazon, at affordable prices, and can be easily incorporated in selfservice health check-up stations for AF screening. Singlelead ECG (e.g., the original AliveCor KardiaMobile) offered superior specificity compared with a pulse-check in a multicentre cohort study by Quinn et al (53).…”

Section: Are We Ready For Launching a National (Uk) Af Screening Programme Using These Stations?mentioning

confidence: 99%

Opportunistic atrial fibrillation screening and detection in “self-service health check-up stations”: a brief overview of current technology potential and possibilities

Boulos¹,

Haywood²

2021

mHealth

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Background Atrial fibrillation (AF): a silent killerAF is the commonest pathological arrhythmia in the world and in population-based studies is found to be present in around 3% of the world's population aged over 20 (1). When it is associated with risk factors such as age over 65, hypertension or diabetes mellitus it confers a significant increase in the risk of stroke (2). All current cardiological guidelines stress the importance of detecting AF, calculating the level of increased risk using the CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke or transient ischaemic attack (TIA), Vascular disease, Age 65 to 74 years, Sex category] score and the institution of appropriate treatment to protect from stroke and thromboembolism.One important problem is the fact that up to around one third of AF may be asymptomatic (2), and it is possible that this accounts for a large proportion of the 20% of patients who suffer a stroke without any apparent underlying

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Diagnostic accuracy and yield of screening tests for atrial fibrillation in the family practice setting: a multicentre cohort study

Cited by 20 publications

References 38 publications

Estimated stroke risk, yield, and number needed to screen for atrial fibrillation detected through single time screening: a multicountry patient-level meta-analysis of 141,220 screened individuals

Estimated stroke risk, yield, and number needed to screen for atrial fibrillation detected through single time screening: a multicountry patient-level meta-analysis of 141,220 screened individuals

Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study

Opportunistic atrial fibrillation screening and detection in “self-service health check-up stations”: a brief overview of current technology potential and possibilities

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