Should screening elderly patients for atrial fibrillation (A-fib) during primary care visits be as routine as checking blood pressure, respiration, and other vital signs? A new study says the answer is "maybe" for some people.
The use of handheld, single-lead electrocardiograms (ECGs) did not increase diagnoses of A-fib overall in patients aged 65 and older, but it did in patients 85 and up, researchers report in the current issue of the journal Circulation.
"Incorporating single-lead ECGs into routine medical assessments as a new vital sign was widely feasible. Over 90% of people who were offered screening agreed to it and underwent screening," said Steven Lubitz, MD, MPH, of the Cardiac Arrhythmia Service and Cardiovascular Research Center at Massachusetts General Hospital, Boston, who led the study.
Because advanced age is associated with a substantially increased risk of both A-fib and stroke, point-of-care screening might be an efficient use of handheld ECGs, Lubitz said.
"The technology simply requires patients to place their fingers on the device to record an electrocardiogram and can be easily embedded in the routine clinical practice of primary care physicians," he told Medscape Medical News.
The typical person has a 30% lifetime risk of developing A-fib, and the chances of experiencing a stroke associated with the arrhythmia can be reduced significantly with anticoagulants, Lubitz said.
Professional organizations are split about the utility of screening for A-fib. The European Society of Cardiology recommends opportunistic screening with either pulse palpation or ECG rhythm strip at clinic visits for patients 65 and older. The National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand have issued similar guidelines.
However, screening for A-fib is not considered standard of care in the United States ― although Lubitz predicted that that would change.
"I think the guidelines in the United States will evolve in the next few years, because I think we're getting closer to understanding who we should be screening for atrial fibrillation and how we should be screening," Lubitz told Medscape.
"Very Reassuring" Results
The randomized controlled trial found that for patients 85 and older, use of handheld ECGs led to a nearly 2% increase in new diagnoses of A-fib in the screening group compared to conventional care.
The researchers also demonstrated an increased likelihood of diagnosing A-fib during the patient's primary-care encounter than at other sites, such as the emergency department or inpatient settings that might be more costly and resource-intensive. Moreover, the study reported that point-of-care screening was associated with high rates of oral anticoagulation prescriptions written for patients with newly diagnosed A-fib, a finding Lubitz called "very reassuring."
The Mass General researchers used single-lead devices attached to a tablet computer to screen more than 35,000 men and women from 16 primary care sites affiliated with the hospital's practice-based research network.
Half the sites were randomly selected to include the screening intervention, where medical assistants used handheld ECGs at the start of the visit while checking routine vital signs.
The 1-year study screened 91% of eligible patients, demonstrating that single-lead rhythm assessment is feasible as part of routine primary care practice, Lubitz said. This finding supports other studies suggesting that handheld devices can enable rapid and scalable mass screening.
"We demonstrated that integration into routine practice by clinical personnel ― in this case, medical assistants ― is feasible. No study has measured and demonstrated such a high integration with routine care, reflecting both patient interest in screening and feasibility of incorporating screening into busy clinical practices," Lubitz said.
Mobile ECGs with the handheld device take about 30 seconds to perform. In contrast, standard ECGs used in outpatient practices are bulky, and recording the ECG can take roughly 10 minutes.
Anthony Leazzo, DO, chairman of family practice at Northwestern Medicine Delnor Hospital, in Geneva, Illinois, noted that smartwatches provide an alternative technology for detecting A-fib.
But "a handheld, one-lead device would be more beneficial and should be more sensitive by measuring electrical activity similar to a normal ECG," he said.
However, Leazzo said using such technology would need to be cost-effective because the patients at highest risk for A-fib usually are on fixed incomes. Consumer versions of the devices can cost under $100. Lubitz said the actual cost for devices and a software platform used for a medical enterprise may differ.
Handheld ECGs are gradually being integrated into clinical practices, a trend driven by the rapid growth of telemedicine to remotely assess patients, Lubitz said.
"Our work affirmed that single-lead devices generate information for the physician that is actionable, though the proportion of newly detected A-fib cases using a point-of-care ECG screening approach is likely to be very small," Lubitz told Medscape. "For that reason, we think handheld devices are best deployed for people at the highest risk of A-fib and stroke, and age is an excellent surrogate for that determination."
The study was funded by Bristol-Myers Squibb–Pfizer Alliance.
Circulation. March 3, 2022. Abstract
Howard Wolinsky is a Chicago-based medical writer.
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Image 1: Massachusetts General Hospital
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Cite this: Handheld ECGs Ease A-Fib Screening in the Very Elderly - Medscape - Mar 08, 2022.