ShouldweperformmassscreeningforAF?

IsabelleNaultMDCardiacElectrophysiologist

IUCPQ

ScreeningforAF

•  Whoshouldwescreen?

•  Howshouldweperformscreening?

Wilsoncriteriaforscreening

•  CondiEonshouldbeanimportanthealthproblem•  NaturalhistoryofthecondiEonshouldbeunderstood•  ThereshouldbearecognisablelatentorearlysymptomaEcstage

•  Thereshouldbeatesteasytoperformandinterpret,acceptable,accurate,reliable,sensiEveandspecific

•  Thereshouldbeanacceptabletreatment•  Policyonwhoshouldbetreated•  Diagnosisandtreatmentcost-effecEve•  Case-findingshouldbeaconEnuousprocess

AF:FrequentHealthproblem

•  LifeEmeriskofdevelopingAFinpaEents>40yis1in4

•  Lloyd-Jonesetal,Circula4on2004•  FromtheFraminghamHeartStudy

•  Upto75%ofpeopledonotexperiencesymptomswhileinAF

•  Israeletal,JACC2004

Stroke:Importanthealthproblem•  20%ofCVAsareaZributabletoatrialfibrillaEon

•  DuringAF,anEcoagulaEondiminishestheriskofembolismsby2/3

–  Hartetal,AnnInternMed2007;146

•  25%ofCVAsarecryptogenic,orofundeterminedsource

–  Hartetal,LancetNeurol2014;13

•  WithAF,theannualrateofCVAsis4.5%–  ArchInternMed,1994;154:1449-57

PrevalenceofsilentAF

•  DependsonthescreenedpopulaEon– Age– Comorbidity– Recipientofpacemakerordefibrillator– RecentCVAorTIA– Historyofarrhythmia

•  HoweverdependsmostlyonduraEonofmonitoring

SEARCH-AF

•  1000paEents,age>65y•  Pharmacyscreening•  iECG

– AliveCorKardia•  NewlyidenEfiedAFin1.5%

Lowres et an, Thromb Haemonst 2014

OpportunisEcscreening

•  Screenedsubjects– OutpaEentclinic–WatchBPandAliveCor– ≥65yearswithdiabetesorHTN– 1.17%incidenceofAF–  Increaseswithage(0.1%<65years,0.9%65-74,3%≥75years)

•  65yearsandmore– SystemaEcreview–30studies– 1.4%,numberneededtoscreen70

Chanetal,Circula4on2016

Lowresetal,ThrombHaemost2013

STROKESTOPStudy

•  PopulaEonscreeninginpaEentswithoutknownAF

•  Individualsbornin1936-1937(75and76yattheEmeofthestudy)inSweden

•  13331invitaEontoparEcipate,53.8%accepted•  IndexECG,twicedailyECGwithhandheldECGrecorderfor2weeks

•  NewAFdetectedin3.0%ofpaEents•  0.5%ofnewlydiagnosedAFwasfoundonindexECG

SubclinicalAF

•  65yearsandmore– WithelevatedNTproBNPorLAEandCHADSVASc≥2orsleepapneaorBMI≥30

– 256paEents– ConEnuoussubcutaneousmonitoring– Meanfollowup16±4months– AFdetecEonrate34.4%(duraEonfiveminutesormore)

Healeyetal,Circula4on2017

Long-termmonitoring

Embrace,NEJM,2014

Compliance:82%ofsubjectscompleted>3weeksofmonitoringPopulaEonofpaEentswithcryptogenicstroke

AnEcoagulaEonbegunin18.6%ofpaEentsintheexperimentalgroupvs11.1%inthecontrolgroup

PrevalenceofsilentAF:PaEentswithPacemakerorDefibrillator

Dilaverisetal,ClinicalCardiology2017

ConsequencesofsilentAF

•  Onestudy5550paEentswithasymptomaEcAF

•  Adjustedstrokeratein1460untreatedpaEents:4%comparedto1%inmatchedcontrolwithoutAF

•  StrokeriskintreatedvsuntreatedpaEents:1%vs4%

Martinez et al, Thrombos Haemost 2014

SCREENING/MONITORINGDEVICES

Holter

Recording duration 24 hrs/48 hrs/7 days depending on model

Cardiostat-IcenEaConEnuousrecordingduraEonupto14days1leadShowerresistantReplaceableelectrodes

Ziopatch-iRhythm

Continuous monitoring Duration of monitoring up to 14 days Repositioning not recommended

Not available in Canada

SEEQ-MedtronicContinuous telemetry system Data transmitted to Medtronic analysis centre Analysis/notification 24/7

Not available clinically in Canada

Monitoring duration up to 30 days

SpiderFlashExternalLoopRecorder(ELR)EventrecorderRecordsupto40days(lithiumbaZery)or15days(alkalinebaZery)Upto25hoursofECG2leadsOthercompanieshavesimilarproducts(KingofHearts,Braemar)AnalysisbymedicalelectrophysiologytechnicianmaytakealotofEme

InternalLoopRecorder

EventmonitorBaZerylife:upto3years

AliveCorKardia

ApprovedbyFDAandHealthCanada

SEARCH-AFstudy1000paEentsPharmacyscreeningNewAFdiagnosisin1.5%AutomaEcAFdetecEonalgorithmSensiEvity98.5%Specificity91.4%

Lowresetal,ThrombHaemost2014

iPhone80paEents:40sinusrhythm,40AFComparedtoECG

Filterandrecording2minutes:SensiEvity87.5%andspecificity95%Filterandrecording5minutes:SensiEvity95%andspecificity95%

Krivosheietal,EuropaceMay2017

CardiioRhythm

AFdiagnosEcbasedonabsenceofrepeatpaZern

CardiioRhythmsensi;vity93%,specificity98%,PPV53%,NPV99%AliveCorsensi;vity71%,specificity99%,PPV77%,NPV99%

Chanetal,Circula4on2016

PULSE-SMART

Pre-andpostCVETwo-minuterecordingComparedtotelemetry

McManusetal,JCEJanuary2016

AliveCorvsWatchBPOfficeAFIB

Chan et al, Circulation 2012; 135

*Photo not indicative, device tested Watch BP Office and not Watch BP Home

Freedman et al, Circulation 2017

Newtechnologies

•  Thetechmarketisextremelyinvestedinhealthandagreatmanyofthetoolsthathavecomeavailablearethesubjectofmedicalstudies

•  Wecanexpectothertechnologiessoon– Watches– Bracelets– Smartclothing

•  PosiEvescreeningrequireECGconfirmaEon

Smartphones

•  64%ofadultshaveasmartphone

•  50-64years:54%

•  >65years:>27%

http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015

ShouldwescreenforAF?

•  AFisooenasymptomaEcorpresentswithatypicalsymptoms

•  Thereisatreatementproventoreducemorbidity

•  Therearecheap,noninvasive,availableandreliablemeansforscreening

•  SoYES!

CostEffecEveness

•  BasedondatafromSTROKESTOPstudy•  Casebasedscenariofor1000paEents(75-76Y)•  263lesspaEentswithundetectedAF•  8fewerstrokes•  11morelife-years•  12morequalityadjustedlifeyear(QALY)•  4313€perQUALY•  6583€peravoidedstroke

Aronsson et al, Europace 2015

ESCguidelines

Argumentsagainstscreening

•  ThereisincreasingevidencethatthereisliZletemporalcorrelaEonbetweenAFandstroke

•  AlthoughweknowanEcoagulaEonreducesstrokeriskinpaEentswithAF,wedonotknowifanEcoagulaEonalterstheriskofstrokeinpaEentswithshortduraEonsilentatrialarrhythmia(ongoingstudies)–theduraEonthresholdforanEcoagulaEonisnotyetclear

•  Maybetheanswerfornowliesinthemethodofscreening

•  LongduraEonmonitoringinpaEentswithoutpreviousstrokeinwhomshortduraEonAFisdetectedmaybringmorequesEonsthananswers

•  LongduraEonmonitoringforAFinpaEentswithESUSisrequired

•  InpaEentswithoutstroke:

•  Thereis86400secondsinoneday.

•  Chancesthata30secondsmonitoringwillcatchashortduraEonnonsignificantAFisquitesmall.MorechancesofmissingparoxysmalAFthanchancesofcatchingnonsignificantAF.

Screening

•  OpportunisEcscreeninginpaEents≥65YORCHADSscore≥1usingashortduraEonrhythmstrip/ECG/pulsetaking–  HandheldECGseemsthebestapproach–othermeans(pulsepalpaEon,pulseoxymetry)needECGconfirmaEon

•  LongerduraEonscreeninginhighriskpaEents–aoerESUS–nexttalk!

•  AreasforconsideraEonforlongerduraEonalthoughnorecommendaEon–  Sleepapnea,heartfailure,largeleoatrium,highPACburden

Finalword

•  ScreeningforAFshouldbeperformed•  DuraEonofrecordingshoulddependonunderlyingriskofstroke/AF

•  ThereisanurgentneedtobeZerdefinetreatmentthresholdforshortAFepisodeslessthan24hinpaEentswithoutpriorstroke

•  Withtechnologicalprogress,conEnuousmonitoringwithwatches/braceletswillsoonbeavailableandthequesEonwhethertheAFburdenneededtoiniEateanEcoagulaEonwillextendbeyondthepacemakerclinic