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

English version

Autoři: Yi Chen ^aff001; Qi-Fang Huang ^aff001; Chang-Sheng Sheng ^aff001; Wei Zhang ^aff001; Shuai Shao ^aff001; Dian Wang ^aff001; Yi-Bang Cheng ^aff001; Ying Wang ^aff001; Qian-Hui Guo ^aff001; Dong-Yan Zhang ^aff001; Yan Li ^aff001; Nicole Lowres ^aff002; Ben Freedman ^aff002; Ji-Guang Wang ^aff001
Působiště autorů: Center for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China ^aff001; Heart Research Institute, Sydney Medical School, Charles Perkins Center, and Cardiology Department, Concord Hospital, The University of Sydney, Sydney, Australia ^aff002
Vyšlo v časopise: Detection rate and treatment gap for atrial fibrillation identified through screening in community health centers in China (AF-CATCH): A prospective multicenter study. PLoS Med 17(7): e32767. doi:10.1371/journal.pmed.1003146
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pmed.1003146

Souhrn

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 (CHA₂DS₂-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.

Klíčová slova:

Anticoagulants – Atrial fibrillation – Cardiology – Electrocardiography – Health screening – Heart – Ischemic stroke – Patients

Zdroje

1. Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: a global burden of disease 2010 study. Circulation. 2014; 129:837–847. doi: 10.1161/CIRCULATIONAHA.113.005119 24345399

2. Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001; 285:2370–2375. doi: 10.1001/jama.285.18.2370 11343485

3. Naccarelli GV, Varker H, Lin J, Schulman KL. Increasing prevalence of atrial fibrillation and flutter in the United States. Am J Cardiol. 2009; 104:1534–1539. doi: 10.1016/j.amjcard.2009.07.022 19932788

4. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014; 64:e1–76. doi: 10.1016/j.jacc.2014.03.022 24685669

5. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016; 37:2893–2962. doi: 10.1093/eurheartj/ehw210 27567408

6. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007; 146:857–867. doi: 10.7326/0003-4819-146-12-200706190-00007 17577005

7. Friberg L, Rosenqvist M, Lindgren A, Terent A, Norrving B, Asplund K. High prevalence of atrial fibrillation among patients with ischemic stroke. Stroke. 2014; 45:2599–2605. doi: 10.1161/STROKEAHA.114.006070 25034713

8. Lowres N, Neubeck L, Redfern J, Freedman SB. Screening to identify unknown atrial fibrillation: a systematic review. Thromb Haemost. 2013; 110:213–222. doi: 10.1160/TH13-02-0165 23595785

9. Lowres N, Olivier J, Chao TF, Chen SA, Chen Y, Diederichsen A, et al. Estimated stroke risk, yield, and number needed to screen for atrial fibrillation detected through single time screening: a multicountry patient-level meta-analysis of 141,220 screened individuals. PLoS Med. 2019; 16:e1002903. doi: 10.1371/journal.pmed.1002903 31553733

10. Freedman B, Camm J, Calkins H, Healey JS, Rosenqvist M, Wang J, et al. Screening for atrial fibrillation: a report of the AF-SCREEN International Collaboration. Circulation. 2017; 135:1851–1867. doi: 10.1161/CIRCULATIONAHA.116.026693 28483832

11. Yang X, Li S, Zhao X, Liu L, Jiang Y, Li Z, et al. Atrial fibrillation is not uncommon among patients with ischemic stroke and transient ischemic stroke in China. BMC Neurol. 2017; 17:207. doi: 10.1186/s12883-017-0987-y 29202727

12. Guo J, Guan T, Fan S, Chao B, Wang L, Liu Y. Underuse of oral anticoagulants in patients with ischemic stroke and atrial fibrillation in China. Am J Cardiol. 2018; 122:2055–2061. doi: 10.1016/j.amjcard.2018.08.057 30292336

13. Li LH, Sheng CS, Hu BC, Huang QF, Zeng WF, Li GL, et al. The prevalence, incidence, management and risks of atrial fibrillation in an elderly Chinese population: a prospective study. BMC Cardiovasc Disord. 2015; 15:31. doi: 10.1186/s12872-015-0023-3 25953603

14. Wei Y, Xu J, Wu H, Zhou G, Chen S, Wang C, et al. Survey of antithrombotic treatment in rural patients (>60 years) with atrial fibrillation in east China. Sci Rep. 2018; 8:6830. doi: 10.1038/s41598-018-24878-y 29717155

15. Wang JG, Chen Y, Huang QF, Li Y, Freedman B. Rationale and design of the randomized controlled trial of intensive versus usual ECG screening for atrial fibrillation in elderly Chinese by an automated ECG system in the community health centers in Shanghai (AF-CATCH). Cardiovasc Innov App. 2017; 2:273–277.

16. Chang SS, Dong JZ, Ma CS, Du X, Wu JH, Tang RB, et al. Current status and time trends of oral anticoagulation use among Chinese patients with nonvalvular atrial fibrillation: The Chinese Atrial Fibrillation Registry Study. Stroke. 2016; 47:1803–1810. doi: 10.1161/STROKEAHA.116.012988 27283198

17. Siu CW, Lip GY, Lam KF, Tse HF. Risk of stroke and intracranial hemorrhage in 9727 Chinese with atrial fibrillation in Hong Kong. Heart Rhythm. 2014; 11:1401–1408. doi: 10.1016/j.hrthm.2014.04.021 24747420

18. Freedman B, Gersh BJ, Lip GY. Misperceptions of aspirin efficacy and safety may perpetuate anticoagulant underutilization in atrial fibrillation. Eur Heart J. 2015; 36:653–656. doi: 10.1093/eurheartj/ehu494 25548061

19. Vinereanu D, Lopes RD, Bahit MC, Xavier D, Jiang J, Al-Khalidi HR, et al. A multifaceted intervention to improve treatment with oral anticoagulants in atrial fibrillation (IMPACT-AF): an international, cluster-randomised trial. Lancet. 2017; 390:1737–1746. doi: 10.1016/S0140-6736(17)32165-7 28859942

20. Marzec LN, Wang J, Shah ND, Chan PS, Ting HH, Gosch KL, et al. Influence of direct oral anticoagulants on rates of oral anticoagulation for atrial fibrillation. J Am Coll Cardiol. 2017; 69:2475–2484. doi: 10.1016/j.jacc.2017.03.540 28521884

21. Svennberg E, Engdahl J, Al-Khalili F, Friberg L, Frykman V, Rosenqvist M. Mass screening for untreated atrial fibrillation: the STROKESTOP study. Circulation. 2015; 131:2176–2184. doi: 10.1161/CIRCULATIONAHA.114.014343 25910800

22. Proietti M, Mairesse GH, Goethals P, Scavee C, Vijgen J, Blankoff I, et al. A population screening programme for atrial fibrillation: a report from the Belgian Heart Rhythm Week screening programme. Europace. 2016; 18:1779–1786. doi: 10.1093/europace/euw069 27170000

23. Guo Y, Wang H, Zhang H, Liu T, Liang Z, Xia Y, et al. MAFA II Investigators. Mobile photoplethysmographic technology to detect atrial fibrillation. J Am Coll Cardiol. 2019; 74:2365–2375. doi: 10.1016/j.jacc.2019.08.019 31487545

24. Chan NY, Choy CC. Screening for atrial fibrillation in 13,122 Hong Kong citizens with smartphone electrocardiogram. Heart. 2017; 103:24–31. doi: 10.1136/heartjnl-2016-309993 27733533

25. Rosenfeld LE, Amin AN, Hsu JC, Oxner A, Hills MT, Frankel DS. The Heart Rhythm Society/American College of Physicians atrial fibrillation screening and education initiative. Heart Rhythm. 2019; 16:e59–65. doi: 10.1016/j.hrthm.2019.04.007 30954599

26. Halcox JPJ, Wareham K, Cardew A, Gilmore M, Barry JP, Phillips C, et al. Assessment of remote heart rhythm sampling using the AliveCor heart monitor to screen for atrial fibrillation: The REHEARSE-AF Study. Circulation. 2017; 136:1784–1794. doi: 10.1161/CIRCULATIONAHA.117.030583 28851729

Článek Evaluation of systems reform in public hospitals, Victoria, Australia, to improve access to antenatal care for women of refugee background: An interrupted time series design

Článek Participation in adherence clubs and on-time drug pickup among HIV-infected adults in Zambia: A matched-pair cluster randomized trial

Článek Efficacy and safety of bempedoic acid for the treatment of hypercholesterolemia: A systematic review and meta-analysis

Článek Healthy behaviors at age 50 years and frailty at older ages in a 20-year follow-up of the UK Whitehall II cohort: A longitudinal study

Článek Development of a polygenic risk score to improve screening for fracture risk: A genetic risk prediction study

Článek The association of skin autofluorescence with cardiovascular events and all-cause mortality in persons with chronic kidney disease stage 3: A prospective cohort study

Článek Consistent sleep onset and maintenance of body weight after weight loss: An analysis of data from the NoHoW trial

Článek Associations of substance use, psychosis, and mortality among people living in precarious housing or homelessness: A longitudinal, community-based study in Vancouver, Canada

Článek A simplified, combined protocol versus standard treatment for acute malnutrition in children 6–59 months (ComPAS trial): A cluster-randomized controlled non-inferiority trial in Kenya and South Sudan

Článek Health and cost impact of stepping down asthma medication for UK patients, 2001–2017: A population-based observational study

Článek Carrying out embedded implementation research in humanitarian settings: A qualitative study in Cox's Bazar, Bangladesh

Článek Impact of self-imposed prevention measures and short-term government-imposed social distancing on mitigating and delaying a COVID-19 epidemic: A modelling study