Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies

Abstract

Atrial fibrillation (AF) causes a third of all strokes, but often goes undetected before stroke. Identification of unknown AF in the community and subsequent anti-thrombotic treatment could reduce stroke burden. We investigated community screening for unknown AF using an iPhone electrocardiogram (iECG) in pharmacies, and determined the cost-effectiveness of this strategy.Pharmacists performedpulse palpation and iECG recordings, with cardiologist iECG over-reading. General practitioner review/12-lead ECG was facilitated for suspected new AF. An automated AF algorithm was retrospectively applied to collected iECGs. Cost-effectiveness analysis incorporated costs of iECG screening, and treatment/outcome data from a United Kingdom cohort of 5,555 patients with incidentally detected asymptomatic AF. A total of 1,000 pharmacy customers aged ≥65 years (mean 76 ± 7 years; 44% male) were screened. Newly identified AF was found in 1.5% (95% CI, 0.8-2.5%); mean age 79 ± 6 years; all had CHA2DS2-VASc score ≥2. AF prevalence was 6.7% (67/1,000). The automated iECG algorithm showed 98.5% (CI, 92-100%) sensitivity for AF detection and 91.4% (CI, 89-93%) specificity. The incremental cost-effectiveness ratio of extending iECG screening into the community, based on 55% warfarin prescription adherence, would be $AUD5,988 (€3,142; $USD4,066) per Quality Adjusted Life Year gained and $AUD30,481 (€15,993; $USD20,695) for preventing one stroke. Sensitivity analysis indicated cost-effectiveness improved with increased treatment adherence.Screening with iECG in pharmacies with an automated algorithm is both feasible and cost-effective. The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered.

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…Kilka urządzeń obsługiwanych przez pacjenta [136,137] oraz przedłużone ciągłe monitorowanie EKG za pomocą rejestratorów z elektrodą przyklejaną do skóry [138] uzyskały walidację jako metody wykrywania napadowego AF (dodatkowa ryc. 1) [139]. Wykrywania bezobjawowego AF z użyciem nowych technologii, takich jak smartfony z elektrodami EKG, inteligentne zegarki oraz urządzenia do pomiaru ciśnienia tętniczego z algorytmami wykrywania AF, nie poddaneo jeszcze formalnej ocenie w porównaniu z uznanymi metodami wykrywania tej arytmii [140].…”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…120,135 Several patient-operated devices 136,137 and extended continuous ECG monitoring using skin patch recorders 138 have been validated for the detection of paroxysmal AF (Web Figure 1). 139 The detection of asymptomatic AF by new technologies, such as smartphone cases with ECG electrodes, smart watches, and blood pressure machines with AF detection algorithms, has not yet been formally evaluated against an established arrhythmia detection method. 140 …”

Smartphone-based arrhythmia detection: Should we encourage patients to use the ECG in their pocket?

“…The cost-effectiveness of using the AliveCor device to screen for AF was investigated in the Screening Education and Recognition in Community pharmacies of Atrial Fibrillation to prevent stroke in an ambulant population aged ≥65 years study (SEARCH-AF) by Lowres et al [9]. Pharmacists performed pulse palpation and iECG recordings collected by the AliveCor device.…”