The case against structured screening for Atrial Fibrillation in General Practice

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Estella Greene
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The case against structured screening for Atrial Fibrillation in General Practice THE CASE AGAINST STRUCTURED SCREENING FOR ATRIAL FIBRILLATION IN GENERAL PRACTICE or the PCCJ conference Nov 2015 r

1 The case against structured screening for Atrial Fibrillation in General Practice THE CASE AGAINST STRUCTURED SCREENING FOR ATRIAL FIBRILLATION IN GENERAL PRACTICE or the PCCJ conference Nov 2015 r Ivan Benett PwSI Cardiology, Clinical Director for Central Manchester CCG o Declarations of interest For the PCCJ conference Nov 2015 Dr Ivan Benett GPwSI Cardiology Clinical Director for Central Manchester CCG No Declarations of interest

I will argue that the greatest health gain is to anti-coagulate those who are already known to be at risk of stroke, rather than waste time screening for AF.

2 I will argue that the greatest health gain is to anti-coagulate those who are already known to be at risk of stroke, rather than waste time screening for AF. Optimising treatment will save 12 strokes per year, each year, in Central Manchester. As opposed to 6 strokes in the first year if we adopt a screening strategy.

3 e.g. Smith WC, Lee AJ, Crombie IK, Tunstall- Pedoe H. Control of blood pressure in Scotland: the rule of halves. Br Med J 1990;300:981-3.

4 The study is part of the Rotterdam study, a population-based prospective cohort study among subjects aged 55 years and above. The prevalence at baseline was assessed in 6808 participants. Incidence of AF was investigated during a mean followup period of 6.9 years in 6432 persons. We identified 376 prevalent and 437 incident cases. Overall prevalence was 5.5%, rising from 0.7% in the age group years to 17.8% in those aged 85 years and above. The overall incidence rate was 9.9/1000 person years. The incidence rate in the age group years was 1.1/1000 person years, rose to 20.7/1000 person years in the age group years and stabilized in those aged 85 years and above. Prevalence and incidence were higher in men than in women. The lifetime risk to develop AF at the age of 55 years was 23.8% in men and 22.2% in women. Warfarin prevents 3 strokes per 100 patients with AF treated/yr *. *Sandercock P, et al. Atrial fibrillation and stroke. Prevalence in different types of stroke and influence on early and long term prognosis (Oxfordshire community stroke project) BMJ 1997;314:1563-4

5 Is screening for AF effective? YES Cochrane review Systematic and opportunistic screening for AF increases the rate of detection of new cases compared with routine practice. While both approaches have a comparable effect on the overall AF diagnosis rate, the cost of systematic screening is significantly more than that of opportunistic screening from the perspective of the health service provider Moran PS et al., Cochrane Database Syst Rev Apr 30;4:CD doi: / CD pub2. Effectiveness of systematic screening for the detection of atrial fibrillation.

6 Question: How effective is screening for AF? Answer: An extra 2 cases for every 300 people over 65yrs screened in one (first) year. Fitzmaurice DA et al., Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial BMJ Aug 25; 335(7616): 383

7 BUT Many primary care professionals cannot accurately detect AF on an ECG, and interpretative software is not sufficiently accurate to circumvent this problem, even when combined with interpretation by a general practitioner. Diagnosis of atrial fibrillation in the community needs to factor in the reading of electrocardiograms by appropriately trained people.. Mant J et al., Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial BMJ Aug 25; 335(7616): 380

8 Screening was ineffective if performed at annual flu clinics. ECG immediately after pulse assessment is essential. Screening was acceptable to patients but required additional resources. Rhys GC et al., Screening for atrial fibrillation in patients aged 65 years or over attending annual flu vaccination clinics at a single general practice. Qual Prim Care. 2013;21(2):

9 Do the benefits out-weight the costs? Benefits About 150/1,000 > 65 yrs One case/150 >65 yrs detected each year One case /1,000 registered population per year Central Manchester population c220, new cases assume nearly all at risk of stroke 6 extra strokes saved in the 1st year in Central Manchester (3/100/yr saved) Costs Monitoring Cost of drugs Adverse effects Opportunity costs

10 Prevalence of known AF in Central Manchester 5% prevalence of AF in over 65yr olds & 10% in over 75yr olds 1,2,3 In Central Manchester there are 15,000 people over 65 yrs 7% of the population No. of people on GP registers 1,500 = Prevalence 10% in > 65s 1. Hobbs FD, Fitzmaurice DA, Mant J, et al. A randomised controlled trial and cost- effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Health Technol Assess 2005; 9: iii iv, ix x, Heeringa J, van der Kuip DA, Hofman A, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 2006; 27: Fuster V, Ryden LE, Cannom DS, et al ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2011; 123(10): e

11 How many more people will we need to anticoagulate using CHA2DS2vasc? A real life study in British Primary Care Edge et al., PCCJ on-line April 2015 In a study of 9 practices (42,000) 395 had known AF 20 had CHA2DS2VASc = 0 30 had CHA2DS2VASc = 1

12 The proportion of people at risk of stroke according to risk score tool used Breakdown of Stroke Risk according to CHADS2 Breakdown of Stroke Risk according to CHA2DS2-VASc 12% 5% 8% 65% 23% 87% CHA2DS2-VASc = 0 CHA2DS2-VASc = 1 CHADS2 = 0 CHADS2 = 1 CHADS2 > 1 CHA2DS2-VASc > 1

13 Current stroke prevention (anticoagulation) treatment in highrisk groups categorised by both CHADS2 and CHA2DS2-VASc Stroke Risk Pts on anticoagulants Pts not on anticoagulants CHADS > patients 175 (68%) 80 (32%) CHA2DS2-VASc > patients 251 (72%) 94 (28%) Extrapolated to the whole of Central Manchester = about 420 people with known AF who are at risk but not anti-coagulated. Treating these will save 12 strokes per year, every year

14 Priorities for identification and treatment of Atrial Fibrillation 1. Stroke risk assessment and anti-coagulation of people with known AF 2. Treat symptoms of people with known AF 3. Diagnose people early by opportunistic screening

15 Summary It is important to identify new people with AF In a cash & workforce limited environment we need to prioritise The largest health gain is likely to be in properly assessing stroke risk, and managing that risk Identifying/case finding should remain as it is

AF Stroke Prevention Through Screening, Intervention and Patient Choice

AF Stroke Prevention Through Screening, Intervention and Patient Choice Dr Matthew Fay GP Principal The Willows Medical Practice- Queensbury GP Partner Westcliffe Medical Group Trustee AF Association Trustee