Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39280.660567.55 (Published 23 August 2007) Cite this as: BMJ 2007;335:383
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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
Competing interests: No competing interests
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...
[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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Re: Detecting Atrial Fibrillation in general practice - the hidden price
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
Competing interests: No competing interests