A Streamlined Approach to Atrial Fibrillation Screening

Partnership between the Cardiac Rhythm Management Team & Department of Stroke Medicine

1Dowds J, 1Britton J, 1McNair W, 1Turkington L, 1Curry L, 1Williamson R, 2Kinnaird M, 2Scullion E. 2Wiggam MI

2018 Northern Ireland Stroke ConferenceTuesday 12th June 2018

Background

• 15-20% of all strokes caused by Atrial Fibrillation (AF) [1]

• 25% Cryptogenic Strokes with no clear cause found [2]

• Significant proportion will have Paroxysmal AF

(PAF), 24% [3]

[1] World Health Organisation. The atlas of heart disease and stroke. [2] Kishore A, Vail A, Majid A, Dawson J, et al, 2014. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke, 45, 520-6.[3] Sposato LA, Cipriano LE, Saposnik G, Vargas ER, et al, 2015. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurology.

Role for Cardiac Monitoring?

Monitoring Duration period

• 2016 recommendations [4]:

– >12 hours, All patients

– >24 hours, no cause found

• Implications…

– Increased burden on Cardiac monitoring services

• Challenge… Are we screening enough?

[4] National clinical guideline for stroke. Prepared by the Intercollegiate Stroke Working Party. Fifth Edition 2016

ChallengeTertiary Stroke

Service

• 2453 new referrals

• 1452 Inpatients

• 839 Strokes/TIA’s

• 800 Outpatients

• 263 Stroke Day Assessment Service [SDAS] (commenced June

2017)

• 2016 Guidelines

Tertiary Cardiac Monitoring Service

• 3000 Investigations

• 450 AF Screenings

• 234 Same day

• Holter = Resource intensive

• No weekend cover

• Supply/demand issue

Capacity/Demand Issue

• Limited availability

• Forced to be selective

• Prolonged waiting list

• Missed ‘Hot’ period

*2017 data from Sroke Dept, BHSCT **2016 Data from Cardiology, BHSCT

Our Solution

Partnership

• Meetings

• Funding

• Targets

• Networking

New Equipment

• 1-14 days duration

• AF detection

• AF >30sec

• Asymptomatic?

New Workflow

• Fast Analysis

• Quick Turnaround

• Nurse-Led Service

Empowerment

• Core Nurses

• Training

• Support

• Monitor hook-up & removal

Monitors

• Symptom activated

• Real-time snapshot

• Too short?

Event Monitor

• Full disclosure

• 24hr-72hr

• Resource intensive

• Slow analysis

• Cost

Holter ECG

• Auto-detection

• 2-3 years

• Invasive

• Cost

• Too long?

Implantable Loop

• Auto-detection

• 1-30 days

• Remote

• Future?

Mobile Cardiac Telemetry

Novacor R.Test 4

AF detection algorithm, 91% sensitive 9x more likely to detect sustained PAF

New ServiceOld New

Team Cardiac Ambulatory Monitoring team Cardiac Device Review Team

Service General, Cardiology, GP, Stroke etc Stroke Only

Monitor Holter Monitor, Continuous Automatic Event Recorders x18

Analysis Slow Fast

Report Delays Same day

O/P W/L 7-9 months ?

Availability Limited (I/P Mon-Thurs only) Good (18x monitors for Stroke)

Staff Physiologist-led only Physiologist & Stroke Deptpartnership

*New - Nurse-led Inpatient Service

*New – Weekend service

*New – ‘Lunchbox’ Transfer System

Walkthrough

Real Case Example

• 67 year old female

• Admitted with Cryptogenic Stroke

• AF Screening indicated

• Fitted with R.Test 4

Assessment of Service

• Primary outcome measures• Number of patients who received screening

• Percentage of patients who accessed same day screening

• Waiting time for patient who did not receive same day screening

• Assessed over a comparable four month period

– Nov 2016 to Feb 2017 vs

– Nov 2017 to Feb 2018

Results

153

402

0

50

100

150

200

250

300

350

400

450

Old Service New Service

No

. of

Pat

ien

ts

Total Number of Patients Screened• The total number of patients accessing AF

screening more than doubled after introduction of the new

service (402 v 153).

• 162.7% increase

Results

• 28% increase of proportion screened on the day of referral from 51% (78/153) to 79% (318/402)

• 4x more Same-day screenings (78 vs 318)

51%

79%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Old Service New Service

Proportion of Same-day Referral & Screening

Results• Decrease from 144

days to 30 days in average wait for those not accessing same day investigation, p<0.001

• 80% reduction

144

30

0

20

40

60

80

100

120

140

160

Old Service New Sevice

Day

s

Mean Outpatient Waiting time

Conclusion

• >1300 patients Screened, 11 months

• AF detection 5%• Other arrhythmias… VT, heart block, asystole

• Significantly improved AF Screening post Stroke – New ECG monitoring system

– Empowerment of stroke unit staff

– Partnership between Stroke Unit & Cardiac Rhythm Management team

Discussion…

• Longer monitoring duration?

• New or Alternative technology?

• ESUS (Embolic stroke of undetermined source )

John DowdsChief Cardiac Physiologist

Cardiac Device Clinic |BHSCT |E: john.dowds@belfasttrust.hscni.net

John BrittonSenior Cardiac Physiologist

Cardiac Device Clinic |BHSCT |E: john.britton@belfasttrust.hscni.net