Date: 7 August 2018
Opportunities for pharmacists to become involved in atrial fibrillation (AF) screening could help dramatically reduce the number of AF-related strokes, experts in the field say.
AF is the most common arrhythmia and increases the risk of stroke five times with research showing AF is responsible for up to 20% of all strokes.
In Australia it is estimated that some 400,000 people suffer AF but up to a third of these people are undiagnosed.
Associate Professor Luke Bereznicki, Head of Pharmacy and Deputy Head of School of Medicine at University of Tasmania, pointed to data showing that of people admitted to hospital with stroke who were subsequently found to have AF, up to 50% didn’t know they were suffering from it.
‘Silent AF is a significant issue,’ he said.
And apart from the health impacts, the economic impacts of AF are significant. A 2010 report (the latest available) by PricewaterhouseCoopers, titled The Economic Cost of Atrial Fibrillation in Australia, found that in 2008-09 the annual costs to the Australian economy from AF were $1.25 billion, or $5,200 for every person with the condition.
‘By way of comparison, this is over double the estimated per person cost of obesity and higher than the per person cost of cardiovascular disease or osteoarthritis,’ the report noted.
A study published last year, Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies concluded: ‘Community screening in pharmacies is a feasible and cost-effective strategy to identify a sizeable cohort with newly identified AF, at sufficient risk to require OACs for stroke prevention. High overall stroke risk, relatively low oral anticoagulant prescription, and poor knowledge of diagnosed AF sufferers highlight the need for community-based screening and education.’
One of the co-authors of the study, Andrew McLachlan, Professor of Pharmacy (Aged Care) Faculty of Pharmacy and Centre for Education and Research on Ageing at Sydney University, said the study screened a sizeable number of people in the community who were at risk of stroke-related AF.
‘The results of the study demonstrated that careful screening, provision of advice and information, as well as the use of the iECG, was able to identify and refer people at highest risk of stroke due to AF,’ Professor McLachlan said.
‘Importantly, this demonstrated that the approach is not only effective in identifying people through community pharmacy but was also cost-effective. AF screening has considerable scope because the risk factors for AF is highest in the demographics of regular clients in community pharmacy.’
This view is backed by Nicki Elkin, Retail Division Manager of Medtronic, who believes pharmacies are ideally placed to screen for AF.
“There is still a very low awareness of AF in the community,’ she said.
‘Pharmacies have a brilliant opportunity to be leading the way on this through better informing their communities. In pharmacy, you know your patients, their history and their needs, so it follows that this puts pharmacists in an ideal position to identify those people who are at high risk of AF.’
Professor McLachlan says AF screening clearly demonstrates community pharmacists’ commitment to public health and wellness. Rather than a focus on disease management, AF screening has a strong flavour of prevention which he sees as the future of healthcare.
‘Pharmacists can help lead this transition from treatment to prevention by engaging in health screening initiatives,’ he said.
‘In my view AF screening could be included within the “Know your numbers” stroke risk screening initiatives. This type of clinical intervention focuses on evidence-based assessments to quantify and communicate risk of stroke to people in the community. This person-centred approach, which involves active collaboration between people in the community-pharmacists-GPs, has a big focus on best information and empowerment.’
Ms Elkin said although it was estimated there were approximately 400,000 people in Australia living with AF, more than 30 per cent of these people would not know they had it until they experienced an event, such as a stroke.
‘To be able to detect AF in those people unaware they are living with the condition, could save thousands of people from the potentially life-threatening consequences of the disease. There is a very practical and simple way that Australian pharmacy can make a difference through AF screening. It’s a huge opportunity,’ she said
Current guidelines from the European Society of Cardiology for the management of AF recommend opportunistic screening for people aged 65 years and over.
Professor McLachlan stressed that collaboration between pharmacists and doctors was essential in AF screening.
‘Such a scheme only works if pharmacists screen, detect and refer,’ he said.
‘GPs are best-placed to confirm AF risk and instigate appropriate interventions to modify risk. It is clear that many GP practices - including some that have pharmacists - are already using the iECG in the routine screening and care of their patients.”
UTAS’ Associate Professor Bereznicki has done extensive work in AF management and sees pharmacy’s role as quite clearly being one of opportunistic screening, education and advice regarding ongoing management of AF (if present) and any risk factors.
‘It’s important to recognise that while pharmacy screening is reasonably accurate, the findings of opportunistic screening for AF should be considered indicative only, and referral is required for further investigation and management,’ Associate Professor Bereznicki said.
‘Patient need to understand that if AF is detected, further investigation is required to confirm the findings. Screening data provides an indication, and that information is made available to the GP or specialist.’
Professor McLachlan said pharmacies were well placed to provide screening services.
‘The opportunity with AF screening is that people tend to see their pharmacists more than their GP and hence the collaboration between GPs and pharmacists provides the best opportunity for a comprehensive AF screening program to have the greatest impact,’ he said.
Associate Professor Bereznicki described it as ‘opportunistic screening’.
‘It’s having someone in the pharmacy waiting for a script who is 70 years old, perhaps with hypertension or another risk factor, and you can suggest to them that perhaps they would be interested in being screened,’ he said. ‘It’s a perfectly reasonable thing to do in a pharmacy.’
Ms Elkin supports Professor McLachlan’s view regarding collaboration between pharmacists and doctors, but is keen to reinforce the opportunity for pharmacy.
‘The technology is developing all the time and in the past AF screening was one of those things that pharmacies really could not have done because the technology was not available,’ she said.
‘Now you have single-lead ECGs, which could potentially be used in pharmacy but training is required to interpret the ECG strip. Training is also required in using the ‘clinical palpation’ method. The method has substantially lower specificity, which gives rise to a higher level of false positive results which may translate as an inflated number of unnecessary GP referrals.’
Associate Professor Bereznicki said that while some training in the use of the iECG device is needed, this is not particularly complicated, given that a medical practitioner is responsible for further interpretation and diagnosis The AliveCor iECG device, for example, has automatic AF detection.
‘It’s very easy to use and this is highlighted in an Australian study in general practice where two models were piloted – one was a nurse practitioner performing the screening and the other was the receptionist handing the equipment to the patients to test themselves; in both cases, the information was relayed to the GP for further investigation,’ he said.
‘It’s very simple to use the iECG device. However, the protocol involving patient education and referral is very important.’
Ms Elkin said there was now a blood pressure monitor available with an algorithm specifically designed to detect AF. Shown to be highly accurate, the monitor has NICE guidance, and is currently used in primary care in the UK NHS, since they have recognised the value of being able to opportunistically detect AF during a routine check-up.
‘This device shows an icon if it detects AF it so no interpretation is required. It’s either there or it’s not.
‘The pharmacist who is doing the screening doesn’t have to have technical knowledge to interpret it. If the icon comes up the pharmacist refers the patient to the GP and then the normal protocols for an AF patient would follow.’
The advantage of lack of interpretation was highlighted in one study, Triage tests for identifying atrial fibrillation in primary care: a diagnostic accuracy study comparing single-lead ECG and modified BP monitors, which concluded that Microlife AFIB technology performed better for identifying AF in primary care than the single-lead ECG monitors tested, as it does not require expertise for interpretation, while its diagnostic performance was comparable to single-lead ECG analysis by cardiologists.
Regardless of the equipment used, Professor McLachlan would like to see AF screening embedded within a larger program of stroke risk screening services.
‘Our study already demonstrated the feasibility and cost-effectiveness in delivering this intervention in Australian community pharmacy using a pharmacy-led approach, strongly supported by cardiologists and allied health professionals,’ he said.
The Feasibility and cost-effectiveness of stroke prevention through community screening for atrial fibrillation using iPhone ECG in pharmacies study noted: ‘Community screening in pharmacies is a feasible and cost-effective strategy to identify a sizeable cohort with newly identified AF, at sufficient risk to require OACs (oral anticoagulants) for stroke prevention. High overall stroke risk, relatively low oral anticoagulant prescription, and poor knowledge of diagnosed AF sufferers highlight the need for community-based screening and education.’
Ms Elkin said AF screening was in its early stages.
‘AF is where hypertension was 10 years ago when fewer people were aware of the danger of high blood pressure, or doing anything about it,’ she said.
‘Now far more people know about the risk of high blood pressure. AF is in the same position – it is currently very under-known in the community but it is very highly linked to stroke with almost 20 per cent of all strokes being linked to AF.’
AF-related strokes are far more debilitating that non-AF strokes.
‘Community pharmacists need to educate and talk to their patients about AF. Anything we can do through community pharmacies to detect AF early will make a significant difference.’
The need for action is highlighted in a report published in the Medical Journal of Australia in January 2015 which stated: ‘The evolving burden of AF has been influenced by a combination of population ageing, changing patterns of cardiac risk factors and improved survival rates in other, contributory forms of cardiovascular disease. As such, reports from high-income countries have demonstrated that AF exerts a major and evolving public health, social and economic burden.’
The report went on to find the number of adults aged 55 and over with AF is predicted to increase steadily in Australia over the next two decades and concluded, somewhat ominously, that ‘AF will reach epidemic proportions worldwide in the coming decades’.
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