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AF Screening to Reduce Stroke Risk
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Why screen for undiagnosed AF?
• Prevent preventable stroke
• Data from Riks-Stroke and registry1
– Approximately 33% of ischaemic strokes due to AF
– Only 16% of those had received an anticoagulant in the previous 6 months
– 8% of patients in registry had AF that was not previously known
Screening can find unknown AF and facilitate appropriate management
Reference: 1. Friberg L et al. Stroke 2014; 45: 2599-605.
Opportunistic screening recommended1,2
Undiagnosed AF is common*
* 1.4% undiagnosed AF found in screening
study among patients ≥ 65 years old2
Low-cost and easy-to-use screening technology available
Patients with AF at high risk of stroke
Stroke due to AF can be prevented with appropriate oral
anticoagulant therapy
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962. 2. Lowres N et al. Thromb Haemost 2013; 110: 213-22.
Who to screen
• People over 65 years of age
• People at high CV risk
• People with predisposing conditions:
–
–
–
–
–
–
–
hypertension,
heart failure,
coronary artery disease,
obesity,
diabetes mellitus,
chronic kidney disease
obstructive sleep apnoea
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962.
Patient case study #1
Mrs J
Aged 68 years, 3 children, 5 grandchildren
Non-smoker
BP 153/100, currently taking ramipril 10 mg/day
Total cholesterol 5.5 mmol/L
LDL cholesterol 2.5 mmol/L
HDL cholesterol 1.1 mmol/L
BMI 29 kg/m2, waist circumference 82 cm
GORD, osteoarthritis in hands, but generally in good health
Australian absolute cardiovascular disease
risk calculator
Reference: 1. Australian Absolute CVD risk calculator. http://www.cvdcheck.org.au/. Accessed on 3/12/2016
Discussion of Mrs J’s CV Risk Score
• Risk of getting CVD in the next 5 years
• Steps to ensure risk does not increase
Reference: 1. Australian Absolute CVD risk calculator. http://www.cvdcheck.org.au/.
Accessed on 3/12/2016
Interactive question
At what level of 5-year risk would be the point where
you add a statin?
1.
2.
3.
4.
5.
3%
5%
9%
18%
25%
Next management steps
• At a regular check-up you discuss her hypertension, and
– switch her to ACEI/diuretic combination
– provide lifestyle advice regarding low salt diet and weight loss
• You commence statin therapy
Discussion: what would be the next steps
in managing this patient?
Interactive question
Extent of undiagnosed AF: what incidence of
undiagnosed AF might you expect in 75-year-olds?
1.
2.
3.
4.
5.
0.5%
1%
3%
5%
10%
References: 1. Svennberg E, Engdahl J, Al-Khalili F, et al. Circulation.2015;131:2176-84.
STROKESTOP study in 7,173 people aged 75–76
• Study of the use of self-activated hand-held single lead ECG
returned positive AF diagnosis in an additional 3% of all patients
in 2 weeks1
Reference: 1. Svennberg E et al. Circulation 2015; 131: 2176-84.
Screening is effective
• Incidence of previously unknown AF was found to be 1.4% in ≥65
year olds1
• Screening can increase detection rate of new cases of atrial
fibrillation: 1.63% a year compared with 1.04% without systematic
or opportunistic screening2
Systematic screening: invitation for electrocardiography
Opportunistic screening: pulse taking and invitation for electrocardiography if the pulse was irregular
References: 1. Lowres N et al. Thromb Haemost 2013; 110: 213-22. 2. Fitzmaurice DA et al. BMJ 2007; 335: 383.
Screening options
• Irregularly irregular pulse detection
– Pulse palpation1
– BP device, e.g. WatchBP2
Require ECG follow-up if irregularly irregular pulse found
• Electrocardiogram (ECG)1
– Multi-lead
– Single lead device, e.g. AliveCor3
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962. 2. Kearley K et al. BMJ Open 2014; 4: e004565.
3. Orchard J et al. Aust Fam Physician 2014; 43: 315-9.
What is the AliveCor device?
• Heart rate and rhythm monitor
– Single-channel electrocardiogram (ECG)
• CE mark class IIa, FDA class II medical device
• Components
– hardware
– free AliveECG app
– free account on eu.alivecor.com
AliveECG app
• Allows real-time viewing of the recording
• Stores recordings on the mobile device
Newly identified AF found in 1.5% of 1000 customers1
•
1% no history of AF
•
0.5% past history AF, cardioversion > 3yrs ago, no recurrence
Number
Age
Heart rate
CHA2DS2-VASc
(mean)
Newly identified
AF
15
79±6
75±16
3.7±1.1
History AF (In AF)
52
79±7
80±16
3.5±1.2
History AF (In SR)
52
76±6
72±13
3.4±1.4
No history AF
881
76±7
74±12
3.2±1.1
All
1000
76±7
74±13
3.3±1.2
Reference: 1. Lowres N, Neubeck L, Salkeld G, et al. Thromb Haemost.2014; 111: 1167-76.
AF on ECG
• Atrial fibrillation indicated by:
– No P-waves
– Irregular ventricular rhythm
– Baseline may be ‘noisy’ or flat
Normal conduction wave
ECG trace showing AF
slide advance to enlarge
AF on ECG
• Atrial fibrillation indicated by:
– No P-waves
– Irregular ventricular rhythm
– Baseline may be ‘noisy’ or flat
Normal conduction wave
Actual ECG traces to
be provided – can
reviewers provide?
ECG trace showing AF
Mrs J
AF identified using AliveCor
Interactive question
Next steps – Would you:
A. Determine if her AF is paroxysmal or permanent as this affects her symptom
management
B. Ask about symptoms
– If she is truly asymptomatic and the AF has no impact on her quality of life no rate control medication is required if the
rate is well controlled on Holter.
– If there is poor rate control, heart rate slowing medication needs to be started irrespective of whether there are
symptoms or not.
C. Start low dose aspirin to lower stroke risk
D. Determine her stroke risk to guide treatment
Select all options that apply
Next steps
• Reducing stroke risk is essential, regardless of whether a
patient is symptomatic or not1
• OACs have demonstrated a reduction in stroke risk in patients
with AF, and superior to no treatment or aspirin2
• The prescription of anticoagulation should be based on stroke
risk assessed using the CHA2DS2-VASc scoring system1
References: 1. Amerena JV et al. Med J Aust 2013; 199: 592-7. 2. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962.
Aim is to identify who does NOT need anticoagulation
• Stroke risk in AF is a continuum1
• The aim of risk assessment is to identify truly low-risk patients
who do not need any antithrombotic therapy1
• Patients with stroke risk factors should be considered for oral
anticoagulation1,2
Understanding this paradigm shift in risk assessment is
important to reduce the underuse of anticoagulant treatment that
occurs despite evidence of efficacy in reducing stroke risk1,2
References: 1. Lane DA et al. Circulation 2012; 126: 860-5. 2. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962.
CHA2DS2-VASc to assess stroke risk
Risk Factor
C ongestive heart failure/LV dysfunction
H ypertension
A ge ≥ 75 years
D iabetes mellitus
S troke/TIA/TE
Score
1
1
2
1
2
V ascular disease (prior myocardial infarction, peripheral artery
disease, or aortic plaque)
A ge 6574 y
S ex category (ie female gender)
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962.
1
1
1
Calculate Mrs J’s CHA2DS2-VASc score
Mrs J
Aged 68 years, 3 children, 5 grandchildren
Non-smoker
BP 153/100, currently taking ramipril 10 mg/day
Total cholesterol 4.4 mmol/L
HDL cholesterol 1.1 mmol/L
BMI 29 kg/m2, waist circumference 82 cm
GERD, osteoarthritis in hands, but generally in
good health
Parameter
Score
Congestive Heart Failure/LVD?:
0
Hypertension?
+1
Age 65-74 years:
+1
Age ≥75 years
0
Diabetes?
0
Stroke, TIA or thromboermbolism?
0
Vascular disease?
0
Female gender?
+1
Acting on CHA2DS2-VASc score1,2
• CHA2DS2-VASc score of 0: recommendation is no antithrombotic
therapy
• Consider anticoagulation in women if CHA2DS2-VASc score = 2.
Anticoagulation recommended if CHA2DS2-VASc score ≥ 3
• Consider anticoagulation in men if CHA2DS2-VASc score = 1.
Anticoagulation recommended if CHA2DS2-VASc ≥ 2
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: 2893-962. 2. Lane DA et al. Circulation 2012; 126: 860-5.
Implementing screening
• What can you do next week in your practice?
• For example
– Include AF investigation in CVD assessments for patients > 65 years:
pulse palpation, questions regarding symptoms, use ECG or AliveCor
– Include ECG in over 75 assessment
Conclusions
• Screening for AF has been made easier by the development
of new affordable technology and should be encouraged
• May reduce stroke risk
• May be cost effective
Q&A
Appendix: Using the Alivecor app
AliveCor breakthroughs in mobile health
First to “consumerise” ECG analysis
•
Check heart health anywhere, anytime on a
mobile device
•
Share information with patients that typically only
doctors could see
• Backed up by professional healthcare services
• Exponentially fast growing database of ECGs
(~2.5 million)
• More accurate and consistent
than human interpretations
Immediate ECG interpretation with
automatic, FDA-cleared detectors
•
Heart rate
•
Beat fluctuation (BFx)
•
Single-lead heart rhythm
•
Atrial fibrillation detector – a leading
cause of stroke
•
Normal detector – no abnormalities
•
Interference detector – unreadable
•
More algorithms in development:
bradycardia, tachycardia, pause,
heart block, HRV
AliveECG app
• Record ECGs from
multiple patients.
• Add patient
information to each
ECG.
Provider dashboard
•
•
•
•
For health professionals with
patients who use the heart
monitor
Helps provider to review
patients’ ECG data
Free secure web-based portal
(eu.alivecor.com)
Simply “invite” a patient by
entering their email address
Learn more at http://www.alivecor.com/posts/the-provider-dashboard