Atrial fibrillation detection and management. Professor Lis Neubeck Head of Theme Long Term Conditions

Transcription

1 Atrial fibrillation detection and management Professor Lis Neubeck Head of Theme Long Term Conditions

2 Atrial fibrillation Most common cardiac arrhythmia Symptoms range from severely debilitating to none Known risk factors include hypertension, sleep apnoea, and other cardiac diseases Frequent hospitalisations Not included in cardiac rehabilitation

3 Atrial fibrillation More than 92,000 Scottish people are known to have atrial fibrillation (AF) AF increases the risk of stroke by more than 5 fold AF is responsible for 1/3 of strokes People with AF-related strokes twice as likely to die have greater lengths of hospital stay require greater levels of subsequent home care support In the first year alone cost 3 times as much as a stroke that is not associated with AF

4 AF challenges 40% of people with AF have no symptoms and therefore may not be aware of any risk AF increases with age 5% over 65 yrs and 10% over 80 yrs (There are greater than 1 million Scots of pensionable age) Anticoagulant therapy can reduce the risk of a stroke by 2/3 Anticoagulant use is sub-optimal even in those with known AF Knowledge is poor in people with AF AF rates are predicted to triple by 2050

5 Can we detect AF to prevent stroke? Systematic review of AF screening studies 30 studies Pulse palpation or ECG Single time point screening identifies 1.5% previously unknown AF 65 years

6 Detecting AF

7 Identifying AF

8 Key ECG differences Regular rhythm Normal sinus rhythm normal heart rate regular rhythm P waves steady baseline Irregularly irregular rhythm *Reduced heart rate (bradyarrhythmia) may also be observed AF heart rate increased (tachyarrhythmia)* irregularly irregular rhythm no P wave

9

10

11 AliveCor Heart Monitor Single lead iphone based ECG

12 AliveCor Heart Monitor On-device validated algorithm for detection of AF Recordings are automatically transmitted to a secure server Health professional can review ECGs via a secure website Lau, Int J Cardiol 2013;165:193-4

13 1

14 Sinus rhythm Atrial fibrillation

15 Pharmacy based screening To determine: 1. The feasibility of community screening in pharmacies using pulse palpation and single-lead iphone ECG (iecg) 2. The cost-effectiveness of screening using iecg

16 Pharmacy based screening Cross-sectional study design Trained 10 pharmacies across Sydney All customers aged 65 years were eligible Screening: medical history, pulse palpation and iecg All suspected AF: referred to practitioner AliveCor Heart Monitor

17 Outcome measures Primary outcomes: 1. Proportion with newly identified AF 2. Incremental cost effectiveness ratio (ICER) per QALY gained and per stroke avoided

18 Results 1,000 customers screened (mean age 76±7; 44% male) Newly identified AF found in 1.5% Number Age (mean ± SD) ECG rate (mean ± SD) CHA 2 DS 2 -VASc 2 (%) CHA 2 DS 2 -VASc (mean ± SD) Newly identified AF 15 79±6 75± ±1.1 History AF (In AF) 52 79±7 80± ±1.2 History AF (In SR) 52 76±6 72± ±1.4 No history AF ±7 74± ±1.1 All ±7 74± ±1.2

19 Results 23/52 (44%) patients were unaware they had AF 18/23 were on oral anticoagulants Number Age (mean ± SD) ECG rate (mean ± SD) CHA 2 DS 2 -VASc 2 (%) CHA 2 DS 2 -VASc (mean ± SD) Newly identified AF 15 79±6 75± ±1.1 History AF (In AF) 52 79±7 80± ±1.2 History AF (In SR) 52 76±6 72± ±1.4 No history AF ±7 74± ±1.1 All ±7 74± ±1.2

20 Results 100% had CHA 2 DS 2 VASc 2 62/104 (59%) had CHADS score of 2 36/62 (58%) Number Age (mean ± SD) ECG rate (mean ± SD) CHA 2 DS 2 -VASc 2 (%) CHA 2 DS 2 -VASc (mean ± SD) Newly identified AF 15 79±6 75± ±1.1 History AF (In AF) 52 79±7 80± ±1.2 History AF (In SR) 52 76±6 72± ±1.4 No history AF ±7 74± ±1.1 All ±7 74± ±1.2

21 Results- cost effectiveness Incremental cost-effectiveness ratio (ICER): per QALY gained: $AUD 5,988 ( 3,142) per Stroke avoided: $AUD 30,481 ( 15,993) NICE Guidelines: < 20,000 per QALY gained (~ $AUD 43,000 / 25,000)

22 Sensitivity analysis Analysis independent of screening participation rate SENSITIVITY ANALYSIS for ICER per QALY gained Base Case Assumptions 40% treatment adherence 50% treatment adherence 55% treatment adherence 60% treatment adherence 70% treatment adherence 80% treatment adherence $20 per screen Warfarin cost $803.8 pa 5.09 QALYs gained per stroke avoided 98.5% sensitivity and 91.4% specificity for screening $8,509 $6,660 $5,988 $5,428 $4,548 $3,888 Lowres, Thromb Haemost 2014;111:

23 Summary Community screening using iecg is feasible and increases the yield of new AF to enable stroke prevention Community screening is cost-effective and well within the range considered fundable Closing evidence-practice gap for anticoagulant would prevent even more strokes, and improve cost-effectiveness

24 Reflections on pharmacy screening Strengths Highly acceptable Value-add Liked the novel technology People with AF grateful that it was identified Weaknesses Needs incentivisation Managing workflow Research paperwork Follow up with GP Not systematic

25 Reflections on pharmacy screening Strengths Highly acceptable Value-add Liked the novel technology People with AF grateful that it was identified Weaknesses Needs incentivisation Managing workflow Research paperwork Follow up with GP Not systematic

26 Prevention of stroke through atrial fibrillation screening with a single-lead smartphone ECG: overcoming the barriers of practice nurses implementation in the primary care setting Neubeck L, Freedman SB, Lowres N, Salkeld G, Zwar N, Comerford D, Webster R, Denney-Wilson E. National Heart Foundation of Australia NSW Cardiovascular Research Network Research Development Project Grant. ($200,000 AUD) - Electronic decision support tool developed and tested - Recruited 3 general practices - Nurse training programme approved by the Australian Primary Health Care Nursing Association

27 Methods 5 general practices in Sydney, Australia Practice nurses screened patients aged 65 years during flu vaccination period (April June 2015) Immediate provisional diagnosis provided by validated on-device automated algorithm 1 iecg pdf imported into patient s medical record via WiFi 1. Orchard, Eur J Prev Cardiol 2016

28 Process evaluation Process evaluation explored views on acceptability of screening, and perceived barriers and enablers Utilised semi-structured interviews conducted with general practitioners, nurses and practice managers Thematically analysed

29

30 Opportunistic screening to detect atrial fibrillation in Aboriginal adults in Australia Gwynne K, Flaskas Y, O'Brien C, Jeffries TL, McCowen D, Finlayson L, Martin T, Neubeck L, Freedman SB 10-year gap in life expectancy between Aboriginal and non- Aboriginal Australians CVD leading cause of death for Aboriginal Australians Limited evidence about AF in indigenous populations globally Aboriginal health workers conducting AF screening Aim to screen 1500 Aboriginal people aged 45 Estimate the prevalence and age distribution of AF of the Australian Aboriginal population

31 Self-monitoring for AF after cardiac surgery 42 people self-monitored using Alivecor The intervention was feasible and acceptable Participants felt empowered Self-monitoring identified 24% AF recurrence within 17 days of hospital discharge 80% were at high enough stroke risk to warrant consideration of anticoagulation, i.e. CHA2DS2-VASc score 2 Only 30% of recurrences were associated with symptoms Participation also significantly improved AF knowledge Lowres N et al EJCTS 2015

32

33 International AF screening consensus

34

35 Screening devices

36

37 Nurse-led tailored risk reduction in atrial fibrillation Neubeck L, Sanders P, Hendriks J, Peiris D. Heart Foundation of Australia/Vanguard Grant. ($75,000) - RCT recruiting in Sydney and Adelaide - Secondary prevention nurse-led electronic decision support tool - Primary outcome improvement in HRQoL

38 Development of Graphic App for Atrial Fibrillation Education Neubeck L, Gallagher R. Pfizer Australia Pty Ltd/Research Support ($14,000 AUD)

39 Atrial fibrillation detection and management Professor Lis Neubeck Head of Theme Long Term Conditions