2. AF Screening to Reduce Stroke Risk

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5. 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
The largest most recent stroke study confirmed that 33% of strokes are due to AF at the time of the stroke. In 24% AF was known, but only 4% were on anticoagulant,
12% were on aspirin which doesn’t work, and 8% on no antithrombotic. That is 20% of all strokes could be prevented if we could change habits to increase anticoagulant prescription. In Sweden they are attempting this as part of screening (StrokeStop study), to find actionable AF.
9% were unknown at the time of stroke. To prevent these we would need to screen.
Reference
Friberg L, Rosenqvist M, Lindgren A et al. High prevalence of atrial fibrillation among patients with ischemic stroke. Stroke 2014; 45:
Reference: 1. Friberg L et al. Stroke 2014; 45:

6. Opportunistic screening recommended1,2
Undiagnosed AF is common*
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
* 1.4% undiagnosed AF found in screening study among patients ≥ 65 years old2
References
Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Lowres N, Neubeck L, Redfern J et al. Screening to identify unknown atrial fibrillation. A systematic review. Thromb Haemost 2013; 110:
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: Lowres N et al. Thromb Haemost 2013; 110:

7. 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
AF is more prevalent in people over 65 years of age, and with the listed concomitant conditions.
Reference
Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

8. 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

9. Australian absolute cardiovascular disease risk calculator
Discuss available tools for calculating CVD risk
Reference
1. Australian Absolute CVD risk calculator. Accessed on 3/12/2016
Reference: 1. Australian Absolute CVD risk calculator. Accessed on 3/12/2016

10. Discussion of Mrs J’s CV Risk Score
Risk of getting CVD in the next 5 years
Steps to ensure risk does not increase
This slide builds, with the calculated score appearing on slide advance. Discuss with audience anticipated CV risk before revealing answer
Reference: 1. Australian Absolute CVD risk calculator. Accessed on 3/12/2016

12. Discussion: what would be the next steps in managing this patient?
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
Ascertain how many of the audience would bring up AF screening
Discussion: what would be the next steps in managing this patient?

13. Reference: 1. Svennberg E et al. Circulation 2015; 131: 2176-84.
Reference: 1. Svennberg E et al. Circulation 2015; 131:

14. 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
In Sweden, the community based STROKESTOP study in 7,173 people aged 75 who took their own recordings for 2 weeks found 3% with unknown AF
Reference
Svennberg E, Engdahl J, Al-Khalili F et al. Mass Screening for Untreated Atrial Fibrillation: The STROKESTOP Study. Circulation 2015; 131:
Reference: 1. Svennberg E et al. Circulation 2015; 131:

15. 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 review published this year in Thrombosis and Haemostasis [Click] showed incidence of AF in over 65 year olds was 1.4%. This suggests population screening over age 65may be worthwhile
References
Lowres N, Neubeck L, Redfern J et al. Screening to identify unknown atrial fibrillation. A systematic review. Thromb Haemost 2013; 110:
Fitzmaurice DA, Hobbs FD, Jowett S et al. Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial. BMJ 2007; 335: 383.
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: Fitzmaurice DA et al. BMJ 2007; 335: 383.

16. 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
Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Kearley K, Selwood M, Van den Bruel A et al. Triage tests for identifying atrial fibrillation in primary care: a diagnostic accuracy study comparing single-lead ECG and modified BP monitors. BMJ Open 2014; 4: e
Orchard J, Freedman SB, Lowres N et al. iPhone ECG screening by practice nurses and receptionists for atrial fibrillation in general practice: the GP-SEARCH qualitative pilot study. Aust Fam Physician 2014; 43:
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: Kearley K et al. BMJ Open 2014; 4: e Orchard J et al. Aust Fam Physician 2014; 43:

17. 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

18. AliveECG app Allows real-time viewing of the recording
Stores recordings on the mobile device

19. 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
Showed newly identified AF in 1.5% of pharmacy customers, mean age 79 – this is similar what has been found in other studies
Those with newly identified AF had a resting heart rate that was not elevated and about the same as their age.
All 15 had a stroke risk score greater than 2 indicating anticoagulation treatment should be given, and with a mean CHADS-VASC score of 3.4
Reference
1. Lowres N, Neubeck L, Redfern J et al. Screening to identify unknown atrial fibrillation. A systematic review. Thromb Haemost 2013; 110:
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)
76±6
72±13
3.4±1.4
No history AF
881
76±7
74±12
3.2±1.1
All
1000
74±13
3.3±1.2
Reference: 1. Lowres N, Neubeck L, Salkeld G, et al. Thromb Haemost.2014; 111:

20. 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
ECG trace showing AF
slide advance to enlarge

21. 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

22. Mrs J AF identified using AliveCor

23. Select all options that apply
Next Steps: Poll
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.
Guidelines suggest paroxysmal may be associated with lower stroke risk than persistent although net clinical benefit of OAC therapy is almost universal & therefore should be used in most patients with AF (2016 ESC guidelines). The intention is to highlight that stroke risk is still significant with paroxysmal AF.
Select all options that apply

24. 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
Amerena JV, Walters TE, Mirzaee S et al. Update on the management of atrial fibrillation. Med J Aust 2013; 199:
Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
References: 1. Amerena JV et al. Med J Aust 2013; 199: Kirchhof P et al. Eur Heart J 2016; 37:

25. 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
References
Lane DA, Lip GY. Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation 2012; 126:
Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
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: Kirchhof P et al. Eur Heart J 2016; 37:

26. CHA2DS2-VASc to assess stroke risk
Risk Factor Score
C ongestive heart failure/LV dysfunction 1
H ypertension 1
A ge ≥ 75 years 2
D iabetes mellitus 1
S troke/TIA/TE 2
V ascular disease (prior myocardial infarction, peripheral artery disease, or aortic plaque) 1
A ge 6574 y 1
S ex category (ie female gender) 1
Reference
1. Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Reference: 1. Kirchhof P et al. Eur Heart J 2016; 37:

27. Calculate Mrs J’s CHA2DS2-VASc score
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?:
Hypertension? +1
Age years:
Age ≥75 years
Diabetes?
Stroke, TIA or thromboermbolism?
Vascular disease?
Female gender?

28. 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
Kirchhof P, Benussi S, Kotecha D et al ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:
Lane DA, Lip GY. Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation 2012; 126:
References: 1. Kirchhof P et al. Eur Heart J 2016; 37: Lane DA et al. Circulation 2012; 126:

29. 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
Encourage the participants to think about how they could implement opportunistic screening for AF in their practices.

30. 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

32. Appendix: Using the Alivecor app

33. 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

34. 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

35. AliveECG app Record ECGs from multiple patients.
Add patient information to each ECG.
Deleted text: Select the recording
Tap Annotate Icon (box with pencil) to add patient information
Symptoms & Activities tracking
Medical Conditions

36. Learn more at http://www.alivecor.com/posts/the-provider-dashboard
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 address
Not available to patients.
Learn more at