Detecting and Diagnosing Atrial Fibrillation (D2AF): study protocol for a cluster randomised controlled trial

Abstract

BackgroundAtrial fibrillation is a common cause of stroke and other morbidity. Adequate treatment with anticoagulants reduces the risk of stroke by 60 %. Early detection and treatment of atrial fibrillation could prevent strokes. Atrial fibrillation is often asymptomatic and/or paroxysmal.Case-finding with pulse palpation is an effective screening method, but new methods for detecting atrial fibrillation have been developed. To detect paroxysmal atrial fibrillation ambulatory rhythm recording is needed.This study aims to determine the yield of case-finding for atrial fibrillation in primary care patients. In addition, it will determine the diagnostic accuracy of three different case-finding methods.Methods/DesignIn a multicenter cluster randomised controlled trial, we compare an enhanced protocol for case-finding of atrial fibrillation with usual care. We recruit 96 practices. We include primary care patients aged 65 years or older not diagnosed with atrial fibrillation. Within each practice, a cluster of 200 patients is randomly selected and marked. Practices are evenly randomised to intervention or control group. The allocation is not blinded.When a marked patient visits an intervention practice, the case-finding protocol starts, consisting of: pulse palpation, sphygmomanometer with automated atrial fibrillation detection and handheld single-lead electrocardiogram (ECG). All patients with at least 1 positive test and a random sample of patients with negative tests receive a 12-lead ECG. Patients without atrial fibrillation on the 12-lead ECG, undergo additional continuous Holter and use the handheld single-lead ECG at home for 2 weeks.Control practices provide care as usual.The study runs for 1 year in each cluster. The primary outcomes are the difference in detection rate of new AF between intervention and control practices and the accuracy of three index tests to diagnose AF. We are currently recruiting practices.The ‘Detecting and Diagnosing Atrial Fibrillation’ (D2AF) study will determine the yield of an intensive case-finding strategy and the diagnostic accuracy of three index tests to diagnose atrial fibrillation in a primary care setting.Trial registrationNetherlands Trial Register: NTR4914, registered on the 25 of November 2014.

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

“…The SAFE study 19,84 therefore remains the primary source of evidence for a comparison of different screening strategies. This situation should change, as three ongoing studies 26,40,85,86 are due to report within the next 3 years. In particular, the STROKESTOP study 26,40 aims to report the impact of screening on long-term outcomes (stroke and mortality), for which there is currently no robust evidence.…”

Opportunistic screening versus usual care for detection of atrial fibrillation in primary care: cluster randomised controlled trial

“…Since the publication of the SAFE study in 2007, numerous devices have been developed to screen for atrial fibrillation (eg, electronic blood pressure monitors with an atrial fibrillation detection function and handheld single lead electrocardiographic devices) 10. We performed the Detecting and Diagnosing Atrial Fibrillation (D 2 AF) study to investigate whether opportunistic screening in primary care patients increased the detection of atrial fibrillation compared with usual care 11. Three methods were used to detect atrial fibrillation: pulse palpation, electronic blood pressure measurement with an atrial fibrillation algorithm, and ECG with a handheld single lead electrocardiographic device.…”

Current practice of Dutch cardiologists in detecting and diagnosing atrial fibrillation: results of an online case vignette study

“…Several new techniques have been introduced to improve detection of AF, e. g. single-lead ECG, modified sphygmomanometers and finger-probe devices [ 9 , 10 ]. We are currently conducting a trial to test the effectiveness of case-finding of AF by general practitioners (GPs), using some of these new techniques [ 11 ]. Part of the study will describe ‘usual care’ by GPs, i. e. how GPs currently diagnose AF.…”