Detection rate and treatment gap for atrial fibrillation identified through screening in community health centers in China (AF-CATCH): A prospective multicenter study

Abstract

Background Atrial fibrillation (AF) is underdiagnosed and especially undertreated in China. We aimed to investigate the prevalence of unknown and untreated AF in community residents (≥65 years old) and to determine whether an education intervention could improve oral anticoagulant (OAC) prescription. Methods and findings We performed a single–time point screening for AF with a handheld single-lead electrocardiography (ECG) in Chinese residents (≥65 years old) in 5 community health centers in Shanghai from April to September 2017. Disease education and advice on referral to specialist clinics for OAC treatment were provided to all patients with actionable AF (newly detected or undertreated known AF) at the time of screening, and education was reinforced at 1 month. Follow-up occurred at 12 months. In total, 4,531 participants were screened (response rate 94.7%, mean age 71.6 ± 6.3 years, 44% male). Overall AF prevalence was 4.0% (known AF 3.5% [ n = 161], new AF 0.5% [ n = 22]). The 183 patients with AF were older ( p < 0.001), taller ( p = 0.02), and more likely to be male ( p = 0.01), and they had a higher prevalence of cardiovascular disease than those without AF ( p < 0.001). In total, 85% (155/183) of patients were recommended for OAC treatment by the established guidelines (CHA 2 DS 2 -VASc ≥ 2 for men; ≥ 3 for women). OAC prescription rate for known AF was 20% (28/138), and actionable AF constituted 2.8% of all those screened. At the 12-month follow-up in 103 patients (81% complete), despite disease education and advice on specialist referral, only 17 attended specialist clinics, and 4 were prescribed OAC. Of those not attending specialist clinics, 71 chose instead to attend community health centers or secondary hospital clinics, with none prescribed OAC, and 15 had no review. Of the 17 patients with new AF and a class 1 recommendation for OAC, only 3 attended a specialist clinic, and none were prescribed OAC. Of the 28 AF patients taking OAC at baseline, OAC was no longer taken in 4. Ischemic stroke ( n = 2) or death ( n = 3) occurred in 5/126 (4%), with none receiving OAC. As screening was performed at a single time point, some paroxysmal AF cases may have been missed; thus, the rate of new AF may be underestimated. Conclusions We demonstrated a noticeable gap in AF detection and treatment in community-based elderly Chinese: actionable AF constituted a high proportion of those screened. Disease education and advice on specialist referral are insufficient to close the gap. Before more frequent or intensive screening for unknown AF could be recommended in China, greater efforts must be made to increase appropriate OAC therapy in known AF to prevent AF-related stroke....

World Heart Federation Roadmap on Atrial Fibrillation – A 2020 Update

“…PPG on smartphones seems the most scalable option, but the diagnosis still requires an ECG for confirmation -that is, another test -which poses challenges. Smartphone ECG devices can provide an AF diagnosis without another test and have been used successfully for screening in many countries, including LMICs [25,28,[112][113][114] (Figure 2). However, many LMICs do not have a ready access to expert ECG readers required to confirm the rhythm, or even 12-lead digital ECG recorders with a valid automated algorithm.…”

Atrial Fibrillation Detected by Single Time-Point Handheld Electrocardiogram Screening and the Risk of Ischemic Stroke

“…promoting patient education and referral similar to the approach used in our study was also ineffective in increasing OAC utilization in patients aged ≥65 years in China, 28 and appears to be a disappointing strategy for closing the therapeutic gap. A recent European study demonstrated a direct correlation between patients' education level and knowledge about OAC in AF, and was lowest in patients without schooling compared to those with college and university education (p<0.05).…”

“…29 Our intervention study to increase OAC use by increasing patient awareness and knowledge showed no impact, but given the low recruitment rate was underpowered to assess effects on OAC uptake, and would also not likely be scalable. Another study by Chen et al promoting patient education and referral similar to the approach used in our study was also ineffective in increasing OAC utilization in patients aged !65 years in China, 28 and appears to be a disappointing strategy for closing the therapeutic gap. A recent European study demonstrated a direct correlation between patients' education level and knowledge about OAC in AF, and was lowest in patients without schooling compared with those with college and university education (p < 0.05).…”

“…OAC prescription rate is much lower in Asia (e.g. Hong Kong, Taiwan and mainland China 28 ) than in high-income countries. We have previously reported that patients with AF in Hong Kong had low knowledge level about AF and OAC therapy which were barriers to stroke prevention.…”

Quarterly versus annual ECG screening for atrial fibrillation in older Chinese individuals (AF-CATCH): a prospective, randomised controlled trial

“…All participants with newly detected atrial fibrillation and participants with untreated known atrial fibrillation (who were excluded from the trial) were included in an educational intervention programme, which included a one-on-one disease educational intervention programme (involving one-on-one disease education with the research cardiologist at the community health centre and provision of educational materials, involving information on risk of stroke associated with atrial fibrillation, the appropriate treatment options of atrial fibrillation, and benefits and risks of anticoagulants, as well as information on how to make an appointment at a designated specialist clinic near each community) and advice to attend a specialist clinic for consultation and OAC prescription. 20 We aimed to improve oral anticoagulants prescription in patients with actionable atrial fibrillation by an educational intervention, to finally reduce the risk of atrial fibrillationrelated strokes.…”