Accuracy of methods for diagnosing atrial fibrillation using 12-lead ECG: A systematic review and meta-analysis

Taggar, Jaspal; Coleman, Tim; Lewis, Sarah; Heneghan, Carl; Jones, Matthew

doi:10.1016/j.ijcard.2015.02.014

Cited by 44 publications

(24 citation statements)

References 17 publications

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“…One reported the accuracy of methods for detecting an irregular pulse and suspected AF; 77 the other reported the accuracy of methods for diagnosing AF using 12-lead ECG. 78 In addition, a systematic review of the DTA of automated blood pressure monitors for opportunistic AF detection, 79 and a review and meta-analysis of the DTA of the algorithm for AF detection during automated blood pressure measurement 80 have been published. These reviews are summarised in Table 7.…”

Section: Guidance From Nice (Medical Technologies Guidance Mtg13)mentioning

confidence: 99%

Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis

Welton

McAleenan

Thom

et al. 2017

Health Technol Assess

122

116

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BackgroundAtrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of thromboembolic events. Anticoagulation therapy to prevent AF-related stroke has been shown to be cost-effective. A national screening programme for AF may prevent AF-related events, but would involve a substantial investment of NHS resources.ObjectivesTo conduct a systematic review of the diagnostic test accuracy (DTA) of screening tests for AF, update a systematic review of comparative studies evaluating screening strategies for AF, develop an economic model to compare the cost-effectiveness of different screening strategies and review observational studies of AF screening to provide inputs to the model.DesignSystematic review, meta-analysis and cost-effectiveness analysis.SettingPrimary care.ParticipantsAdults.InterventionScreening strategies, defined by screening test, age at initial and final screens, screening interval and format of screening {systematic opportunistic screening [individuals offered screening if they consult with their general practitioner (GP)] or systematic population screening (when all eligible individuals are invited to screening)}.Main outcome measuresSensitivity, specificity and diagnostic odds ratios; the odds ratio of detecting new AF cases compared with no screening; and the mean incremental net benefit compared with no screening.Review methodsTwo reviewers screened the search results, extracted data and assessed the risk of bias. A DTA meta-analysis was perfomed, and a decision tree and Markov model was used to evaluate the cost-effectiveness of the screening strategies.ResultsDiagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age.ConclusionsA national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations.LimitationsMany inputs for the economic model relied on a single trial [the Screening for Atrial Fibrillation in the Elderly (SAFE) study] and DTA results were based on a few studies at high risk of bias/of low applicability.Future workComparative studies measuring long-term outcomes of screening strategies and DTA studies for new, emerging technologies and to replicate the results for photoplethysmography and GP interpretation of 12-lead electrocardiography in a screening population.Study registrationThis study is registered as PROSPERO CRD42014013739.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Guidance From Nice (Medical Technologies Guidance Mtg13)mentioning

confidence: 99%

Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis

Welton

McAleenan

Thom

et al. 2017

Health Technol Assess

122

116

View full text Add to dashboard Cite

show abstract

“…Third, single ECG interpretations required a cardiologist for interpretation because the hand-held ECG device did not have a built-in AF algorithm to provide real-time results. This may change with the development of highly specific automatic algorithms for AF detection 31. Fourth, we could have overdiagnosed some cases of new AF when participants could have had a prior diagnosis and were unaware because history of AF was based on self-report alone.…”

Section: Discussionmentioning

confidence: 99%

High prevalence of modifiable stroke risk factors identified in a pharmacy-based screening programme

et al. 2016

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BackgroundPopulation-based screening for atrial fibrillation (AF) is a promising public health strategy to prevent stroke. However, none of the published reports have evaluated comprehensive screening for additional stroke risk factors such as hypertension and diabetes in a pharmacy setting.MethodsThe Program for the Identification of ‘Actionable’ Atrial Fibrillation in the Pharmacy Setting (PIAAF-Pharmacy) screened individuals aged ≥65 years, attending community pharmacies in Canada, who were not receiving oral anticoagulation (OAC). Participants were screened for AF using a hand-held ECG device, had blood pressure (BP) measured, and diabetes risk estimated using the Canadian Diabetes Risk Assessment Questionnaire (CANRISK) questionnaire. ‘Actionable’ AF was defined as unrecognised or undertreated AF. A 6-week follow-up visit with the family physician was suggested for participants with ‘actionable’ AF and a scheduled 3-month visit occurred at an AF clinic.ResultsDuring 6 months, 1145 participants were screened at 30 pharmacies. ‘Actionable’ AF was identified in 2.5% (95% CI 1.7 to 3.6; n=29); of these, 96% were newly diagnosed. Participants with ‘actionable AF’ had a mean age of 77.2±6.8 years, 58.6% were male and 93.1% had a CHA2DS2-VASc score ≥2. A BP>140/90 was found in 54.9% (616/1122) of participants and 44.4% (214/492) were found to be at high risk of diabetes. At 3 months, only 17% of participants were started on OAC, 50% had improved BP and 71% had confirmatory diabetes testing.ConclusionsIntegrated stroke screening identifies a high prevalence of individuals who could benefit from stroke prevention therapies but must be coupled with a defined care pathway.

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“…A systematic review compared the accuracy of different methods for interpreting 12-lead ECGs for AF diagnosis. 3 Compared with ECGs interpreted by trained cardiac specialists, automated software analysis had greater specificity for AF diagnosis than other HCPs. 3 Automated software therefore has the potential to be used as a triage tool to correctly identify normal ECGs that do not require further analysis; ECGs identified as abnormal would warrant further interpretation by a trained professional.…”

Section: 3mentioning

confidence: 98%

Correction

2016

Br J Gen Pract

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get to help us identify who's more at risk than the next person.QOF encouraged us to identify chronic kidney disease (CKD), and now overburdened by its commonness, we are at risk of throwing away all we have achieved. Few diagnoses are predictably associated with such a dramatic increase in cardiovascular risk and none are so easily identified by a cheap and easily available blood test. 2,3The clustering of vascular pathologies with diabetes and hypertension makes this burden of disease the greatest challenge for the next generation of patients and doctors.We investigated the reassurance given by NICE, that the previous decade's CKD QOF initiative had improved the identification and management of CKD. In a practice population of 10 264, 9% of adults aged ≥18 years had a diagnosis of CKD on repeated testing. Despite this remarkable prevalence (usual estimates 3-6%), a total of 75% of these patients with CKD were unaware of the diagnosis, and in more than 25% both GP and patients were unaware of the condition. The results demonstrated that this lack of awareness was not limited to those with mild renal compromise but applied to onethird of patients with CKD stage 4. Our short intervention, either by phone or letter, significantly improved attainment of NICE (health indicator and education) criteria but also identified the continued confusion between CKD and lower urinary tract symptoms.It's time to remember why we estimated renal function in the first place. In a world of uncertainty, this is information for free. When associated with hypertension, diabetes, proteinuria, and vascular disease -pause -look again and feel confident that CKD means something. The lower the number the higher the risk.

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Accuracy of methods for diagnosing atrial fibrillation using 12-lead ECG: A systematic review and meta-analysis

Cited by 44 publications

References 17 publications

Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis

Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis

High prevalence of modifiable stroke risk factors identified in a pharmacy-based screening programme

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