Detection of atrial fibrillation in primary care

Abstract

Effectiveness and feasibility of two strategies to screen for AF in primary care. In chapter2 we examined a programmatic approach in which research nurses screened for AF during influenza vaccination in primary care practices. With this programmatic approach 35% of the population that visited the influenza vaccination sessions was screened and 1.1% of them was newly detected with AF. All screen-detected AF cases were aged ≥60 years and detection rate increased with age up to 4.9% in those aged ≥85 years. The vast majority of these cases were eligible for anticoagulation treatment (19% had a CHA2DS2-VASc score of 1, and 78% a CHA2DS2-VASc score of 2 or more). In chapter 3 we found that this screening approach was almost definitely cost-effective (nearly 99.8% of the simulations) and most likely cost saving (62% of the simulations) for identifying new cases of AF in the population aged ≥65 years. In chapter4 we examined an opportunistic approach in which screening was left at discretion of coworkers of GP practices. In a cluster randomized trial 15 intervention GP practices used the same hand-held single-lead ECG devices at their own discretion to screen all patients aged at least 65 years that visited the practice and 16 control practices provided usual care. The coworkers of intervention practices managed to screen 11% of the eligible population during one study year. Even though the yield was high in the screened group (28 of 919; 3.0%), this did not result in an increased AF detection rate when compared to usual care (both 1.4% during one study year). Patients that were selected for screening by GP practices had more comorbidities as compared to patients that were not screened. Do patients with screen-detected AF more often experience AF-related signs and symptoms than patients without AF? In chapter5 we found that 44% of the patients with screen-detected AF consulted the general practice with AF signs or symptoms two years prior to diagnosis, but this was overall not significantly more than age- and gender matched controls (34%). Signs and symptoms included shortness of breath, fatigue, dizziness, chest pain, (near)syncope, symptoms suspicious for TIA/minor stroke, and palpation of an irregular pulse. Palpitations and an irregular pulse were significantly more prevalent in screen-detected cases than controls: 9.8% vs. 3.7% and 9.8% vs. 0.4%, respectively. In chapter6 we describe a study in which patients filled out a questionnaire just before screening about presence of AF-related symptoms during the past month; palpitations, skipped heart beats, shortness of breath, chest discomfort, dizziness and/or lightheadedness. AF was detected in 3.0% of all patients aged ≥65 years that were screened. Patients with screen-detected AF reported significantly more often AF-related symptoms than those without AF (64.0% versus 44.2%). Most frequently reported were palpitations (32.0% versus 11.7%) and shortness of breath (36.0% versus 15.8%), while dizziness occurred more often among patients without AF (4.0% versus 13.2%). Patients who experienced palpitations or shortness of breath had a twice or more chance of AF at screening; 7.2% and 6.0%, respectively.