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Rapid Responses: Rapid Responses published:
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Find and Treat
- Rizaldy Pinzon (5 August 2007)
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Screening of atrial fibrillation by measurement of brain natriuretic peptide.
- Giuseppe Lippi, Martina Montagnana, Gian Cesare Guidi. (7 August 2007)
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Detecting Atrial Fibrillation in general practice - the hidden price
- Andrew M Thornett (9 August 2007)
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Risk of stroke with paroxysmal and permanent atrial fibrillation is the same
- srikanth s, MD achanta, chicago,60612 illinois ,usa (12 August 2007)
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Re: Detecting Atrial Fibrillation in general practice - the hidden price
- DA Fitzmaurice (31 August 2007)
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Rizaldy Pinzon, Neurologist Stroke Unit Bethesda Hospital Yogyakarta INDONESIA
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This article is very interesting. The large number of study subjects is the main strength of this interesting article. Atrial fibrillation is responsible for approximately one in seven strokes in patients of all ages and for one in four strokes in patients aged >80 years. Although the average annual risk of stroke is approximately 5%, there is substantial risk heterogeneity within the population of patients with atrial fibrillation(1). In subjects from the original cohort of the Framingham Heart Study, atrial fibrillation (AF) was associated with a 1.5- to 1.9- fold mortality risk after adjustment for the preexisting cardiovascular conditions with which AF was related. The decreased survival seen with AF was present in men and women and across a wide range of ages. By pooled logistic regression, after adjustment for age, hypertension, smoking, diabetes, left ventricular hypertrophy, myocardial infarction, congestive heart failure, valvular heart disease, and stroke or transient ischemic attack, AF was associated with an odds ratio for death of 1.5 (95% CI, 1.2 -1.8) in men and 1.9 (95% CI, 1.5-2.2) in women (2). Preventive action is mandatory. Find the AF in aging population, and treat the condition properly. Compared with aspirin, oral anticoagulant significantly decreases the risk of all strokes, ischemic strokes, and cardiovascular events for patients with non-valvular chronic or paroxysmal atrial fibrillation but modestly increases the absolute risk of major bleeding. The balance of benefits and risks varies by patient subgroupi. Treating 1,000 patients for one year with oral anticoagulants rather than aspirin would prevent 23 ischaemic strokes while causing nine additional major bleeding episodes(3). The other review suggest that warfarin could prevent 30 strokes at the expense of only 6 additional major bleeds. Aspirin could prevent 17 strokes, without increasing major hemorrhage. In direct comparison, there was moderate evidence for fewer strokes among patients on warfarin than on aspirin [aggregate OR=0.64 [95% CI 0.43-0.96]], with only suggestive evidence for more major hemorrhage [OR =1.58 [95% CI 0.76-3.27]](4). This article remind us to actively find the AF, and treat the AF properly, especially in high risk group. References 1. Anderson DC, Koller RL, Asinger RW, Bundlie SR, Pearce LA. Atrial fibrillation and stroke: Epidemiology, pathophysiology, and management. Neurologist 1998; 4(5):235-258. 2.Benjamin EJ, Wolf PA, D'Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 1998; 98(10):946-952. 3. van Walraven C, Hart RG, Singer DE et al. Oral anticoagulants vs aspirin in nonvalvular atrial fibrillation. An individual patient meta- analysis. Journal of the American Medical Association 2002; 288: 2441- 2448 4. Segal JB, McNamara RL, Miller MR et al. Anticoagulants or antiplatelet therapy for non-rheumatic atrial fibrillation and flutter. (Cochrane Review). In: The Cochrane Library, Issue 1 2003. Oxford: Update Software. Competing interests: None declared |
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Giuseppe Lippi, Associate Professor of Clinical Biochemistry Sez. Chimica Clinica, Dip. Scienze Morfologico-Biomediche, Verona University, 37134 - Verona, Italy., Martina Montagnana, Gian Cesare Guidi.
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The prevalence of atrial fibrillation (AF), a major risk factor for thromboembolic disease and stroke, rises with age, reaching nearly 5% in people aged over 65. We read with interest the recent article of Fitzmaurice et al., who concluded that active screening for atrial fibrillation in general practice by means of a simple low cost test will be advocated to identify new cases that would benefit from an earlier triage, especially antithrombotic treatment (1). The approach used by Fitzmaurice et al. was conceived on a simple opportunistic intervention, by pulse taking and invitation for electrocardiography if the pulse was irregular. It has recently been highlighted that the measurement of natriuretic peptides, namely the brain natriuretic peptide (BNP), is a valuable diagnostic tool to identify precociously a variety of subclinical disorders besides heart failure, including preclinical states of myocardial disease and asymptomatic arrhythmias (2). In particular, moderate elevations in plasma BNP level, below the threshold of the diagnosis of heart failure, are associated with a high risk of AF (3). BNP values are commonly increased in patients with AF and normal ventricular function (4), and its plasma concentration decreases after conversion to sinus rhythm (5). It has also been emphasized that AF, in absence of high ventricular rate, induces an asymptomatic cardiac alteration that is not detectable by echocardiography, but could be reliably identified by BNP alterations (6). Finally, preoperative BNP levels are higher in patients who exhibit postoperative echocardiography abnormalities and it may play a role in preoperative risk stratification (7). Therefore, although we agree that opportunistic screening with pulse taking followed by electrocardiography is an effective and suitable approach (1), it should also be considered that the use of a simple biochemical test, such as BNP measurement, might retain several advantages. In fact, it is a single, relatively inexpensive and scarcely invasive blood test that can be performed in patients referred to clinical laboratories for routine blood testing, and it is also widely available to GPs and hospital wards as a ‘point-of-care’ assay (8). Therefore, we suggest that BNP measurement should be considered as an alternative and cost-effective approach to screen for atrial fibrillation in patients aged 65 or over. References 1. Fitzmaurice DA, Hobbs FD, Jowett S, Mant J, Murray ET, Holder R, Raftery JP, Bryan S, Davies M, Lip GY, Allan TF. Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial. BMJ 2007 Aug 2. 2. McKie PM, Burnett JC Jr. B-type natriuretic peptide as a biomarker beyond heart failure: Speculations and opportunities. Mayo Clin Proc 2005;80:1029-36. 3. Wang TJ, Larson MG, Levy D, Benjamin EJ, Leip EP, Omland T, et al. Plasma natriuretic peptide levels and the risk of cardiovascular events and death. N Engl J Med 2004;350:655-63. 4. Silvet H, Young-Xu Y, Walleigh D, Ravid S. Brain natriuretic peptide is elevated in outpatients with atrial fibrillation. Am J Cardiol 2003;92:1124-7. 5. Wozakowska-Kaplon B. Effect of sinus rhythm restoration on plasma brain natriuretic peptide in patients with atrial fibrillation. Am J Cardiol 2004;93:1555-8. 6. Jourdain P, Bellorini M, Funck F, Fulla Y, Guillard N, Loiret J et al. Short-term effects of sinus rhythm restoration in patients with lone atrial fibrillation: a hormonal study. Eur J Heart Fail 2002;4:263-7. 7. Cuthbertson BH, Amiri AR, Croal BL, Rajagopalan S, Alozairi O, Brittenden J, Hillis GS. Utility of B-type natriuretic peptide in predicting perioperative cardiac events in patients undergoing major non- cardiac surgery. Br J Anaesth 2007;99:170-6. 8. Cuthbertson BH, Amiri AR, Croal BL, Rajagopalan S, Alozairi O, Brittenden J, Hillis GS. Utility of B-type natriuretic peptide in predicting perioperative cardiac events in patients undergoing major non- cardiac surgery. Br J Anaesth 2007;99:170-6. Competing interests: None declared |
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Andrew M Thornett, Senior Clinical Lecturer in Medical Education & General Practitioner Faculty of Health, Staffordshire University, Blackheath Lane, Stafford, ST18 0AD
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One year ago, I became a principal in general practice. In partnership with another general practitioner, I took over a large single handed practice with a significant elderly population. The findings of this study are most relevant to a population such as ours, where improved recognition of Atrial Fibrillation is likely to lead to the great improvements in outcome. Such screening would inevitably become a part of the Quality and Outcomes Framework (QOF), which is based on the axiom that increased screening is a pre-requisite for improvements in health care in primary care. For a large number of indicators within the QOF, practices must screen all patients in a particular group for indicators of disease, and then treat according to guidelines to achieve changes in health risk status (Department of Health, 2007). However, every time a new indicator is added to the framework, such as annual electrocardiograms for all patients over 65 years old, this has significant workload and associated cost implications for the practice. The QOF may link increased income with such a screening programme but it is likely to come from other areas and care is still expected to remain at its previous high level in the areas from which the funds are removed. Consequently, primary care staff must find the extra time using existing resources. Diverting time and energy to taking electrocardiograms will result in another aspect of healthcare having reduced time spent in that area. The group of patients who benefit from screening electrocardiograms are also the same group that suffers from coronary heart disease, chronic obstructive pulmonary disease, chronic kidney disease and depression. They require time spent on these areas too. In practice, the QOF has already reduced the time available to listen to patients’ concerns, explain the nature and implications of their illnesses to them and to address their immediate worries. For Balint, the health professional is the drug (Ballint, 2000), and Pendleton et al believe that it is important to spend time reaching a shared understanding of illness (Pendleton et al., 2003). Even Neighbour’s five key tasks included a process of negotiation (Neighbour, 1994), which is now at risk. My worry is that these aspects of the consultation will be lost as we strive to introduce more and more screening procedures and targeted care into the primary care consultation. BALLINT, M. (2000) The doctor, his patient and the illness, London, Elsevier Health Sciences. Department of Health (2007) Updated version of original QOF guidance and evidence base. http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Primarycare/Primarycarecontracting/QOF/DH_4125653 [accessed 9/7/08]. NEIGHBOUR, R. (1994) The Inner Consultation: How to Develop an Effective and Intuitive Consulting Style, Norwell, USA, Kluwer Academic Pubishers. PENDLETON, D., SCHOFIELD, T., HAVELOCK, P. & TATE, P. (2003) The New Consultation : Developing Doctor-Patient Communication, Oxford, Oxford University Press. Competing interests: None declared |
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srikanth s, MD achanta, Resident John stroger Hospital of cook county, chicago,60612 illinois ,usa
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The article highlights importance of basic clinical skills in identifying a cardiac condition accounting for most of the hospitalizations related to cardiac arrhythmias. This study has some interesting aspects like, Part of the general examination itself is a screening procedure and its confirmation with most effective test EKG, other thing is its cost effectiveness. So it is once again proven that how important is basic clinical skills in day to day clinical life and its impact on the outcome of health care. This should be emphasized not only in primary care setting but also in medical school and residency training which helps them to become perfect when they enter in to practice . Coming to this article how many times we ‘ll be successful in identifying an irregular pulse in atrial fibrillation. The most common type of atrial fibrillation is paroxysmal atrial fibrillation, which is characterized by repeated, self terminating episodes of arrhythmia. This can progress to either persistent atrial fibrillation, in which an intervention such as direct current cardio version may restore sinus rhythm, or permanent atrial fibrillation, which is resistant to cardio version. So the question is with this simple screening method can we identify asymptomatic pts with paroxysmal atrial fibrillation who are about to get in to permanent fibrillation .Inviting pts for electrocardiography based on irregular pulse may miss some pts with PAF because the change in rate, rhythm and character of their pulse depends on how often they get episodes of AF but the risk of stroke is same with both paroxysmal and permanent AF.Hence stopping further investigation based on absence irregular pulse may not properly guide further management in some subset of pts unless symptomatic. Some other effective screening methods which needs further studies are “heart rate variability, circulating levels of natriuretic peptide, Circulating levels of collagen type I degradation marker (depend on the type of atrial fibrillation). So in my opinion even though pulse taking with EKG would be a cost effective and quick screening method when compared to above we need further studies to have a best screening method to identify all kinds of asymptomatic pts. References 1.Onset mechanism of paroxysmal atrial fibrillation detected by ambulatory Holter monitoring Antonio Vincenti*, Roberta Brambilla, Maria Grazia Fumagalli, Rita Merola and Stefano Pedretti Electrophysiology and Cardiac Pacing Unit, Cardiology DepartmentSt Gerardo Hospitalvia Donizetti 106, 20052 Monza (MI) Italy 2.Dimitrios N. Tziakas1,*, Georgios K. Chalikias1, Nikolaos Papanas2, Dimitrios A. Stakos1, Sofia V. Chatzikyriakou1 and Efstratios Maltezos21 University Cardiology Department, Democritus University of Thrace, Voulgaroktonou 23, 68100 Alexandroupolis, Evros, Greece; 2 Second University Internal Medicine Department, Democritus University of Thrace, Alexandroupolis, Evros, Greece 3.Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Hart RG, Benavente O, McBride R, Pearce LA.Department of Medicine (Neurology), University of Texas Health Science Center, San Antonio 78284, USA. Competing interests: None declared |
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DA Fitzmaurice, Professor of Primary Care University of Birmingham B15 2TT
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Might I suggest Dr Thornett actually reads the paper! The SAFE study concludes that opportunistic screening, using pulse taking and only ECG for those with an irregular pulse is the most cost-effective method of screening and actually discourages the routine use of population based ECG screening. Competing interests: None declared |
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