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Screening for AF by pulse assessments effective?

Screening for atrial fibrillation in patients aged 65 years or over attending annual flu vaccination clinic at a single general practice.

Abstract

BACKGROUND:
Atrial fibrillation (AF) is a common, treatable cause of stroke. Screening is recommended at influenza vaccination ('flu') clinics, but not implemented nationally.

OBJECTIVES:
We aimed to determine if screening for AF by pulse assessment of those aged ≥ 65 years attending flu vaccination is effective, practical and feasible. The success of screening was determined by discovery of undiagnosed cases, estimating the prevalence of undiagnosed AF, assessing the accuracy of a second-year General Practice Specialty Trainee (GPST2) and interpretative software at diagnosing AF on electrocardiography (ECG), completion without disrupting routine practice, estimating cost-effectiveness and guiding future screening.

DESIGN:
Patients ≥ 65 years old attending flu clinics were screened. Patients with an irregular pulse had an ECG, with interpretation by the GPST2, interpretative automated software and a reporting service.

RESULTS:
A total of 573 patients were screened, identifying 95 patients with an irregular pulse: 21 had prior AF, 5 were < 65 years old and 1 had a previous myocardial infarction (MI); 68 were invited for ECG, of whom 39 attended; 2 new cases of AF were diagnosed. Pre-screening AF prevalence was 12.2% in those aged ≥ 75 years, and 12.4% after screening. A new case was discovered for every 286 patients screened. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 100% for the GPST2 and interpretative software for ECG diagnosis of AF versus cardiological assessment. Identifying a new case cost approximately £234. Limitations included low uptake of ECG appointments, and delayed and low completion of ECGs, leading to missed AF diagnoses.

CONCLUSIONS:
Screening was ineffective. ECG immediately after pulse assessment is essential. Screening was acceptable to patients but required additional resources. Age groups 65-74 and ≥ 85 years were not adequately screened using flu clinics. Novel methods screening older, non-attending patients are required. Practices should introduce annual pulse checks into chronic disease templates and prompts for those aged ≥ 65 years attending surgery. Additional screening should target practices with low AF prevalence or poor rates of opportunistic screening.

Rhys GC, Azhar MF, Foster A.Source

Keele University, Staffordshire ST5 5BG, UK