Atrial fibrillation detection
(For the main atrial fibrillation project page please click here)
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. 1.5 million people in England are estimated to have the condition but one third of these patients are undiagnosed.
Prevalence of AF rises with age and it is anticipated that the number of people with AF will double over the next 20 years. AF is a major cause of stroke and having AF increases a person’s stroke risk by around 20%. Strokes caused by AF tend to be more severe, resulting in higher mortality and greater residual disability.
Many cases of AF are detectable by a simple pulse check.
NICE Clinical Guidance (embed link) on AF recommends manual pulse palpation to assess for the presence of an irregular pulse that may indicate underlying atrial fibrillation in people presenting with:
- Chest discomfort
AF commonly occurs in association with factors such as hypertension, diabetes and ischaemic heart disease and NICE recommends that these patients be screened when they attend for routine review. A simple way of achieving this in primary care would be to add a pulse rhythm prompt to all chronic disease management templates within the GP system
The SAFE study found that routine screening in primary care of patients aged 65 and over was an effective method of detecting AF.
The Arrhythmia Alliance have developed a “Know your pulse” campaign consisting of promotional posters, digital apps and instructional videos. These could be promoted within General Practice and other health care venues to raise patient awareness and encourage them to ask their healthcare professional for a pulse check.
Detecting AF can prove challenging in some cases as the abnormal rhythm can frequently be experienced intermittently (paroxysmal AF, PAF). PAF carries the same stroke risk as persistent or permanent AF and these patients should be anticoagulated as per standard guidelines.
Often, admission to hospital with TIA or a minor stroke can be the first manifestation of arrhythmia and so interventions to detect paroxysmal AF can be very beneficial in these settings. Stroke patients with untreated AF have a very high risk of having a recurrent stroke but if the AF is managed appropriately this risk can be reduced.
NICE recommends that for people with suspected paroxysmal AF:
- A 24 hour ambulatory ECG monitor is used in those with suspected asymptomatic episodes, or symptomatic episodes less than 24 hours apart
- An event recorder ECG is used in those with symptomatic episodes more than 24 hours apart
BMJ Open. 2016 Nov 10;6(11):e012714
Lancet Neurol. 2017 Feb 8. pii: S1474-4422(17)30002-9. doi: 10.1016/S1474-4422(17)30002-9.
There are a number of mobile ECG recorders on the market. These can be used in a range of health care settings to improve detection rates for AF.
- Do you routinely screen patients for AF in your practice?
- What do you think the challenges would be in implementing an AF screening programme?
- How could you best utilise mobile ECGs in the AF detection pathway?