Opportunistic screening for atrial fibrillation by clinical pharmacists in UK general practice during the influenza vaccination season: A cross-sectional feasibility study

Abstract

Background Growing prevalence of atrial fibrillation (AF) in the ageing population and its associated life-changing health and resource implications have led to a need to improve its early detection. Primary care is an ideal place to screen for AF; however, this is limited by shortages in general practitioner (GP) resources. Recent increases in the number of clinical pharmacists within primary care makes them ideally placed to conduct AF screening. This study aimed to determine the feasibility of GP practice–based clinical pharmacists to screen the over-65s for AF, using digital technology and pulse palpation during the influenza vaccination season. Methods and findings Screening was conducted over two influenza vaccination seasons, 2017–2018 and 2018–2019, in four GP practices in Kent, United Kingdom. Pharmacists were trained by a cardiologist to pulse palpate, record, and interpret a single-lead ECG ( SL ECG). Eligible persons aged ≥65 years (y) attending an influenza vaccination clinic were offered a free heart rhythm check. Six hundred four participants were screened (median age 73 y, 42.7% male). Total prevalence of AF was 4.3%. All participants with AF qualified for anticoagulation and were more likely to be male (57.7%); be older; have an increased body mass index (BMI); and have a CHA 2 DS 2 -VASc (Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes, previous Stroke, Vascular disease, Age 65–74 years, Sex category) score ≥ 3. The sensitivity and specificity of clinical pharmacists diagnosing AF using pulse palpation was 76.9% (95% confidence interval [CI] 56.4–91.0) and 92.2% (95% CI 89.7–94.3), respectively. This rose to 88.5% (95% CI 69.9–97.6) and 97.2% (95% CI 95.5–98.4) with an SL ECG. At follow-up, four participants (0.7%) were diagnosed with new AF and three (0.5%) were initiated on anticoagulation. Screening with SL ECG also helped identify new non-AF cardiovascular diagnoses, such as left ventricular hypertrophy, in 28 participants (4.6%). The screening strategy was cost-effective in 71.8% and 64.3% of the estimates for SL ECG or pulse palpation, respectively. Feedback from participants (422/604) was generally positive. Key limitations of the study were that the intervention did not reach individuals who did not attend the practice for an influenza vaccination and there was a limited representation of UK ethnic minority groups in the study cohort. Conclusions This study demonstrates that AF screening performed by GP practice–based pharmacists was feasible, economically viable, and positively endorsed by participants. Furthermore, diagnosis of AF by the clinical pharmacist using an SL ECG was more sensitive and more specific than the use of pulse palpation alone. Future research should explore the key barriers preventing th...

Pharmacy-Based Opportunistic Atrial Fibrillation Screening at a Community Level: A Real-Life Study

“…Several single-lead AF screening trials have been performed in community pharmacies ( Table 4 ) [ 6 , 7 , 14 , 15 , 16 , 17 ]. However, no data is available regarding the proportion of people detected in a population community included in an AF screening pharmacy program.…”

“…Indeed, distribution of pharmacies throughout the national territory allows large AF screening in general population particularly in non-urban areas where shortage of medical doctor is increasingly significant. Additionally, compared with pulse palpation or no detection, opportunistic AF screening implemented in pharmacies has been considered to be cost-effective in UK [ 16 ]. On the other hand, screening disease induces anxiety in participants and the psychological harm results in being labelled with an unexpected disease diagnosis [ 20 ].…”

Integrated Care for Atrial Fibrillation Management: The Role of the Pharmacist

“…Thirteen studies have tested the feasibility of pharmacist-led atrial fibrillation screening programmes (Table 1). [4][5][6][7][8][9][10][11][12][13][14][15][16] Three of these also attempted to characterize atrial fibrillation by assessing symptoms 12 or using the CHA 2 DS 2 -VASc score to quantify stroke risk. 8,11 None of these studies have characterized atrial fibrillation by severity of atrial fibrillation burden or substrate severity.…”

“…15 One study did not specify the device used to generate the single-lead ECG, 12 and another study used the Microlife AFIB in isolation to detect atrial fibrillation. 10 Manual pulse palpation was performed in five studies, 5,6,9,12,16 and in one study 12 this was combined with a symptom and risk factor assessment.…”

“…Study settings varied but were predominantly conducted in community pharmacies (n=7). 4,7,10,12,[14][15][16] The incidence of new atrial fibrillation was reported in eight studies 4,5,7,9,12,[14][15][16] and ranged from 0.7% 5 to 6.3%. 9 Other studies only reported cases of possible atrial fibrillation, 6,8,10,11 and no results were available for one study.…”