Yield of Screening for Atrial Fibrillation in Primary Care With a Hand-held, Single-lead Electrocardiogram Device During Influenza Vaccination

Femke Kaasenbrood; Monika Hollander; Frans H. Rutten; Leo J. Gerhards; Arno W. Hoes; Robert G. Tieleman

Disclosures

Europace. 2016;18(10):1514-1520. 

In This Article

Abstract and Introduction

Abstract

Aims To assess the yield of screening for atrial fibrillation (AF) with a hand-held single-lead electrocardiogram (ECG) device during influenza vaccination in primary care in the Netherlands.

Methods and results We used the MyDiagnostick to screen for AF in persons who participated in influenza vaccination sessions of ten Dutch primary care practices. In case of suspected AF detection by the stick, the recorded 1-min ECG registrations were analysed by a cardiologist. We scrutinized electronic medical files of the general practitioners to obtain information about the cases screened. Multivariable logistic regression analysis was performed to predict the relation between patient characteristics and a new screen-detected diagnosis of AF. In total, 3269 persons were screened for AF during the influenza vaccination sessions of 10 general practitioner practices. As a result, 37 (1.1%) new cases of AF were detected. Prior transient ischeamic attack or stroke (OR 6.05; 95%CI 1.93–19.0), and age (OR 1.09 per year; 95% CI 1.05–1.14) were independent predictors for such newly screen-detected AF. Of the 37 screen-detected AF cases, 2.7% had a CHA2DS2-VASc of 0, 18.9% a score of 1, and 78.4% a score of 2 or more. The majority needed oral anticoagulant therapy.

Conclusions Screening seems feasible with an easy to use single-lead, hand-held ECG device with automatic AF detection during influenza vaccination in primary care and results in a '1-day' yield of 1.1% new cases of AF.

Introduction

Atrial fibrillation (AF) affects 1–2% of the total population, with prevalences increasing with age.[1] If untreated, AF increases the risk of ischaemic stroke, heart failure, and mortality.[2] Anticoagulants are very effective and reduce the stroke risk by 60%, and all-cause mortality by 25%.[3] Underdiagnosis of AF is, however, common and may at least partly be related to a lack of symptoms, so-called 'silent AF'.[4] In patients admitted with an ischaemic stroke in the presence of AF, the arrhythmia was unknown in one-fourth to almost half of the patients.[5,6] Early detection of AF followed by adequate anticoagulation can help prevent ischaemic strokes.[1] Older age and co-morbidities such as heart failure, hypertension, diabetes, prior transient ischeamic attack (TIA)/stroke, and vascular disease (CHA2DS2-VASc score) drive the risk of thromboembolism.[7] Guidelines recommend to prescribe anticoagulation therapy to AF patients with a CHA2DS2-VASc score of 1 or more (or 2 or more), independent of whether AF is paroxysmal or persistent, screen detected, or diagnosed in patients with symptoms.[1,4,8,9]

The 2010 European Society of Cardiology (ESC) guidelines recommend screening for AF among those aged 65 years and over in primary care, for instance by pulse palpation during blood pressure measurement, and followed by an electrocardiogram (ECG) in case of irregularity.[1] Practice studies in primary care showed that active pulse feeling is infrequently performed nowadays, and there seems to be room for improvement of (early) detection of AF with devices.[10] Non-invasive devices such as specialized blood pressure monitors that automatically detect AF (MicroLife RR monitor), and devices that register single-lead ECGs (AliveCor, MyDiagnostick) may be considered good alternatives for AF screening.[11,12] The MyDiagnostick is an easy to apply device that registers and automatically analyses a single-lead I rhythm strip after holding the device with both hands for one minute. It signals a red light in case of rhythm irregularity suspicious for AF, and a green light in case of absence of AF. The rhythm strip can be visualized and analysed by linking the device to a computer. A recent validation study showed that the sensitivity and negative predictive value of a green light signal was very good (both 100%) in a cardiology setting with a prevalence of AF of 28%. In a pilot study, this device seemed feasible as a screening tool during influenza vaccination in primary care.[12] These results need confirmation in a larger study to quantify the yield of selective 'mass screening' during influenza vaccination.

Every autumn, general practitioners (GPs) in the Netherlands invite eligible community-dwelling persons for a 1-day influenza vaccination session. Dutch indications for influenza vaccination are: (i) age 60 years or over, and (ii) for younger persons, (a history of) diabetes mellitus, COPD, asthma, ischaemic heart disease, or heart failure.[13] This setting provides an ideal opportunity for selective screening of a large population of community-dwelling persons who are at increased risk of AF.

We aim to (i) calculate the proportion of newly detected cases, (ii) assess feasibility of large-scale screening with a single-lead ECG device during influenza vaccination, (iii) evaluate the patient characteristics most predictive for a new screen-detected diagnosis of AF, (iv) determine the CHA2DS2-VASc score of novel screen-detected cases and compare these with known cases with AF who received influenza vaccination, and (v) identify enablers and barriers to the implementation of screening with the MyDiagnostick during influenza vaccination.

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