Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies

Summary Atrial fibrillation (AF) causes a third of all strokes, but often goes undetected before stroke. Identification of unknown AF in the community and subsequent anti-thrombotic treatment could reduce stroke burden. We investigated community screening for unknown AF using an iPhone electrocardiogram (iECG) in pharmacies, and determined the cost-effectiveness of this strategy. Pharmacists performed pulse palpation and iECG recordings, with cardiologist iECG over-reading. General practitioner review/12-lead ECG was facilitated for suspected new AF. An automated AF algorithm was retrospectively applied to collected iECGs. Cost-effectiveness analysis incorporated costs of iECG screening, and treatment/outcome data from a United Kingdom cohort of 5,555 patients with incidentally detected asymptomatic AF. A total of 1,000 pharmacy customers aged ≥65 years (mean 76 ± 7 years; 44% male) were screened. Newly identified AF was found in 1.5% (95% CI, 0.8–2.5%); mean age 79 ± 6 years; all had CHA2DS2-VASc score ≥2. AF prevalence was 6.7% (67/1,000). The automated iECG algorithm showed 98.5% (CI, 92–100%) sensitivity for AF detection and 91.4% (CI, 89–93%) specificity. The incremental cost-effectiveness ratio of extending iECG screening into the community, based on 55% warfarin prescription adherence, would be $AUD5,988 (€3,142; $USD4,066) per Quality Adjusted Life Year gained and $AUD30,481 (€15,993; $USD20,695) for preventing one stroke. Sensitivity analysis indicated cost-effectiveness improved with increased treatment adherence. Screening with iECG in pharmacies with an automated algorithm is both feasible and cost-effective. The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered. Previous Presentation: This study was presented in part as an oral presentation at the Cardiac Society of Australia and New Zealand Conference; 9 August 2013; Sydney, Australia, abstract published in Heart Lung Circulation 2013;22:S223. Trial registration: Australian New Zealand clinical trials registry: ACTRN12612000406808.

[1]  G. Lip,et al.  Patient’s values and preferences for stroke prevention in atrial fibrillation: balancing stroke and bleeding risk with oral anticoagulation , 2014, Thrombosis and Haemostasis.

[2]  Mukul Sharma,et al.  Evaluation of patients’ attitudes towards stroke prevention and bleeding risk in atrial fibrillation , 2013, Thrombosis and Haemostasis.

[3]  E. Antman,et al.  Edoxaban versus warfarin in patients with atrial fibrillation. , 2013, The New England journal of medicine.

[4]  Lennart Bergfeldt,et al.  Atrial Fibrillation, Stroke Risk, and Warfarin Therapy Revisited: A Population-Based Study , 2013, Stroke.

[5]  L. Neubeck,et al.  Fog on the crystal ball? Missing atrial fibrillation in forecasting the future of stroke. , 2013, Stroke.

[6]  J. Spence.  Faculty Opinions recommendation of Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association. , 2013 .

[7]  M. Zálešák,et al.  Higher Persistence in Newly Diagnosed Nonvalvular Atrial Fibrillation Patients Treated With Dabigatran Versus Warfarin , 2013, Circulation. Cardiovascular quality and outcomes.

[8]  Randall T Higashida,et al.  Forecasting the Future of Stroke in the United States: A Policy Statement From the American Heart Association and American Stroke Association , 2013, Stroke.

[9]  C. Anderson,et al.  Adelaide Stroke Incidence Study: Declining Stroke Rates but Many Preventable Cardioembolic Strokes , 2013, Stroke.

[10]  Lis Neubeck,et al.  iPhone ECG application for community screening to detect silent atrial fibrillation: a novel technology to prevent stroke. , 2013, International journal of cardiology.

[11]  C. Teljeur,et al.  Effectiveness of systematic screening for the detection of atrial fibrillation. , 2013, The Cochrane database of systematic reviews.

[12]  Julie Redfern,et al.  Screening to identify unknown atrial fibrillation , 2013, Thrombosis and Haemostasis.

[13]  N. Lowres,et al.  Screening for atrial fibrillation above age 65 detects an asymptomatic subset at high risk of stroke. , 2013, International journal of cardiology.

[14]  C. Martinez,et al.  ADVERSE PROGNOSIS OF ASYMPTOMATIC ATRIAL FIBRILLATION DETECTED INCIDENTALLY: A CASE FOR SCREENING , 2013 .

[15]  B. Yan,et al.  Barriers to Warfarin Use for Stroke Prevention in Patients With Atrial Fibrillation in Hong Kong , 2013, Clinical cardiology.

[16]  Mårten Rosenqvist,et al.  Stepwise Screening of Atrial Fibrillation in a 75-Year-Old Population: Implications for Stroke Prevention , 2013, Circulation.

[17]  G. Lip,et al.  Potential net clinical benefit of population-wide implementation of apixaban and dabigatran among European patients with atrial fibrillation , 2012, Thrombosis and Haemostasis.

[18]  Gerhard Hindricks,et al.  2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation--developed with the special contribution of the European Heart Rhythm Association. , 2012, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[19]  Jeroen J. Bax,et al.  2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. , 2012, European heart journal.

[20]  S. Stewart,et al.  Assessing cardiovascular risk in regional areas: the Healthy Hearts – Beyond City Limits program , 2012, BMC Health Services Research.

[21]  S. Sorensen,et al.  Dabigatran versus rivaroxaban for the prevention of stroke and systemic embolism in atrial fibrillation in Canada , 2012, Thrombosis and Haemostasis.

[22]  N. Lowres,et al.  Screening Education And Recognition in Community pHarmacies of Atrial Fibrillation to prevent stroke in an ambulant population aged ≥65 years (SEARCH-AF stroke prevention study): a cross-sectional study protocol , 2012, BMJ Open.

[23]  G. Mairesse,et al.  Prevalence of atrial fibrillation in adults participating in a large-scale voluntary screening programme in Belgium , 2012, Acta cardiologica.

[24]  E. Rahme,et al.  Sex differences in stroke risk among older patients with recently diagnosed atrial fibrillation. , 2012, JAMA.

[25]  D. Stott,et al.  RCPE UK Consensus Conference on 'Approaching the comprehensive management of atrial fibrillation: evolution or revolution?'. , 2012, The journal of the Royal College of Physicians of Edinburgh.

[26]  A. Capucci,et al.  Subclinical atrial fibrillation and the risk of stroke. , 2012, The New England journal of medicine.

[27]  A. Banerjee,et al.  Net clinical benefit of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus no treatment in a ‘real world’ atrial fibrillation population: A modelling analysis based on a nationwide cohort study , 2011, Thrombosis and Haemostasis.

[28]  Munir Pirmohamed,et al.  Dabigatran etexilate versus warfarin in management of non-valvular atrial fibrillation in UK context: quantitative benefit-harm and economic analyses , 2011, BMJ : British Medical Journal.

[29]  D. Atar,et al.  Apixaban versus warfarin in patients with atrial fibrillation. , 2011, The New England journal of medicine.

[30]  J. Seward,et al.  173 Silent atrial fibrillation in olmsted county: A community-based study , 2011 .

[31]  T. Vos,et al.  The health loss from ischemic stroke and intracerebral hemorrhage: evidence from the North East Melbourne Stroke Incidence Study (NEMESIS) , 2010, Health and quality of life outcomes.

[32]  G. Breithardt,et al.  An international survey of physician and patient understanding, perception, and attitudes to atrial fibrillation and its contribution to cardiovascular disease morbidity and mortality , 2010, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[33]  S. Yusuf,et al.  Dabigatran versus warfarin in patients with atrial fibrillation. , 2009, The New England journal of medicine.

[34]  N. Horne,et al.  Chlamydia testing in community pharmacies: evaluation of a feasibility pilot in south east London , 2007, Quality and Safety in Health Care.

[35]  M. Aguilar,et al.  Meta-analysis: Antithrombotic Therapy to Prevent Stroke in Patients Who Have Nonvalvular Atrial Fibrillation , 2007, Annals of Internal Medicine.

[36]  P. Clarke,et al.  Pharmacy diabetes care program: analysis of two screening methods for undiagnosed type 2 diabetes in Australian community pharmacy. , 2007, Diabetes research and clinical practice.

[37]  Simon Finfer,et al.  SAFE (The Saline versus Albumin Fluid Evaluation) 試験 , 2006 .

[38]  J Raftery,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. , 2005, Health technology assessment.

[39]  S. Sacco,et al.  Contribution of Atrial Fibrillation to Incidence and Outcome of Ischemic Stroke: Results From a Population-Based Study , 2005, Stroke.

[40]  K. Minematsu,et al.  Atrial fibrillation as a predictive factor for severe stroke and early death in 15 831 patients with acute ischaemic stroke , 2005, Journal of Neurology, Neurosurgery & Psychiatry.

[41]  M. Frommer,et al.  Community pharmacy in Australia. , 2004, Australian health review : a publication of the Australian Hospital Association.

[42]  Anthony J Culyer,et al.  National Institute for Clinical Excellence and its value judgments , 2004, BMJ : British Medical Journal.

[43]  A. Briggs.  Statistical approaches to handling uncertainty in health economic evaluation , 2004, European journal of gastroenterology & hepatology.

[44]  G. Lip,et al.  Ethnic Differences in Patient Perceptions of Atrial Fibrillation and Anticoagulation Therapy: The West Birmingham Atrial Fibrillation Project , 2001, Stroke.

[45]  T. Olsen,et al.  Acute stroke with atrial fibrillation. The Copenhagen Stroke Study. , 1996, Stroke.

[46]  Gerard Walschap,et al.  Adelaide , 1912, British medical journal.

[47]  D. DeMets,et al.  Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. , 2013, Journal of the American College of Cardiology.