Publications by authors named "Ben Freedman"

148 Publications

Feasible approaches and implementation challenges to atrial fibrillation screening: a qualitative study of stakeholder views in 11 European countries.

BMJ Open 2022 Jun 21;12(6):e059156. Epub 2022 Jun 21.

Department of Cardiology, University Medical Center Hamburg-Eppendorf, University Heart & Vascular Center Hamburg, Hamburg, Germany.

Objectives: Atrial fibrillation (AF) screening may increase early detection and reduce complications of AF. European, Australian and World Heart Federation guidelines recommend opportunistic screening, despite a current lack of clear evidence supporting a net benefit for systematic screening. Where screening is implemented, the most appropriate approaches are unknown. We explored the views of European stakeholders about opportunities and challenges of implementing four AF screening scenarios.

Design: Telephone-based semi-structured interviews with results reported using Consolidated criteria for Reporting Qualitative research guidelines. Data were thematically analysed using the framework approach.

Setting: AF screening stakeholders in 11 European countries.

Participants: Healthcare professionals and regulators (n=24) potentially involved in AF screening implementation.

Intervention: Four AF screening scenarios: single time point opportunistic, opportunistic prolonged, systematic single time point/prolonged and patient-led screening.

Primary Outcome Measures: Stakeholder views about the challenges and feasibility of implementing the screening scenarios in the respective national/regional healthcare system.

Results: Three themes developed. (1) Current screening approaches: there are no national AF screening programmes, with most AF detected in symptomatic patients. Patient-led screening exists via personal devices, creating screening inequity. (2) Feasibility of screening: single time point opportunistic screening in primary care using single-lead ECG devices was considered the most feasible. Software algorithms may aid identification of suitable patients and telehealth services have potential to support diagnosis. (3) Implementation requirements: sufficient evidence of benefit is required. National screening processes are required due to different payment mechanisms and health service regulations. Concerns about data security, and inclusivity for those without primary care access or personal devices must be addressed.

Conclusions: There is an overall awareness of AF screening. Opportunistic screening appears the most feasible across Europe. Challenges are health inequalities, identification of best target groups for screening, streamlined processes, the need for evidence of benefit and a tailored approach adapted to national realities.
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http://dx.doi.org/10.1136/bmjopen-2021-059156DOI Listing
June 2022

Cost-Effectiveness of Monitoring Patients Post-Stroke With Mobile ECG During the Hospital Stay.

J Am Heart Assoc 2022 04 12;11(8):e022735. Epub 2022 Apr 12.

The Melbourne Brain Centre at the Royal Melbourne Hospital and the University of Melbourne Parkville Australia.

Background The effectiveness of a nurse-led in-hospital monitoring protocol with mobile ECG (iECG) was investigated for detecting atrial fibrillation in patients post-ischemic stroke or post-transient ischemic attack. The study aimed to assess the cost-effectiveness of using iECG during the initial hospital stay compared with standard 24-hour Holter monitoring. Methods and Results A Markov microsimulation model was constructed to simulate the lifetime health outcomes and costs. The rate of atrial fibrillation detection in iECG and Holter monitoring during the in-hospital phase and characteristics of modeled population (ie, age, sex, CHA2DS2-VASc) were informed by patient-level data. Costs related to recurrent stroke, stroke management, medications (new oral anticoagulants), and rehabilitation were included. The cost-effectiveness analysis outcome was calculated as an incremental cost per quality-adjusted life-year gained. As results, monitoring patients with iECG post-stroke during the index hospitalization was associated with marginally higher costs (A$31 196) and greater benefits (6.70 quality-adjusted life-years) compared with 24-hour Holter surveillance (A$31 095 and 6.66 quality-adjusted life-years) over a 20-year time horizon, with an incremental cost-effectiveness ratio of $3013/ quality-adjusted life-years. Monitoring patients with iECG also contributed to lower recurrence of stroke and stroke-related deaths (140 recurrent strokes and 20 deaths avoided per 10 000 patients). The probabilistic sensitivity analyses suggested iECG is highly likely to be a cost-effective intervention (100% probability). Conclusions A nurse-led iECG monitoring protocol during the acute hospital stay was found to improve the rate of atrial fibrillation detection and contributed to slightly increased costs and improved health outcomes. Using iECG to monitor patients post-stroke during initial hospitalization is recommended to complement routine care.
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http://dx.doi.org/10.1161/JAHA.121.022735DOI Listing
April 2022

Alcohol consumption in relation to the incidence of atrial fibrillation in an elderly Chinese population.

J Geriatr Cardiol 2022 Jan;19(1):52-60

School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China.

Background: Alcohol consumption is a known modifiable risk factor for atrial fibrillation. The association, however, might differ according to gender. We investigated gender-specific associations between alcohol consumption and incident atrial fibrillation in an elderly Chinese population.

Methods: Our study participants were elderly residents (≥ 65 years) recruited from five community health centers in the urban area of Shanghai ( = 6,618). Alcohol intake was classified as never drinkers and current light-to-moderate (< 40 g/day) and heavy drinkers (≥ 40 g/day). Atrial fibrillation was detected by a 30-s single-lead electrocardiography (ECG, AliveCor Heart Monitor) and further evaluated with a regular 12-lead ECG.

Results: During a median of 2.1 years (interquartile range: 2.0-2.2) follow-up, the incidence rate of atrial fibrillation was 1.10% in all study participants. It was slightly but non-significantly higher in men ( = 2849) than women ( = 3769, 1.30% . 0.96%, = 0.19) and in current drinkers ( = 793) than never drinkers ( = 5825, 1.64% . 1.03%, = 0.12). In both unadjusted and adjusted analyses, there was interaction between sex and current alcohol intake in relation to the incidence of atrial fibrillation ( < 0.0001). After adjustment for confounding factors, current drinkers had a significantly higher incidence rate of atrial fibrillation than never drinkers in women (12.96% [7/54] . 0.78% [29/3715], adjusted odds ratio [OR] = 10.25, 95% confidence interval [CI]: 3.54-29.67, < 0.0001), but not in men (0.81% [6/739] . 1.47% [31/2110], OR = 0.62, 95% CI: 0.25-1.51, = 0.29).

Conclusions: Our study showed a significant association between alcohol intake and the incidence of atrial fibrillation in elderly Chinese women, but not men.
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http://dx.doi.org/10.11909/j.issn.1671-5411.2022.01.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8832043PMC
January 2022

2021 Asia Pacific Heart Rhythm Society (APHRS) practice guidance on atrial fibrillation screening.

J Arrhythm 2022 Feb 28;38(1):31-49. Epub 2021 Dec 28.

Charles Perkins Centre The University of Sydney Sydney Australia.

In this paper, the Asia Pacific Heart Rhythm Society (APHRS) sought to provide practice guidance on AF screening based on recent evidence, with specific considerations relevant to the Asia-Pacific region. A key recommendation is opportunistic screening for people aged ≥65 years (all countries), with systematic screening to be considered for people aged ≥75 years or who have additional risk factors (all countries).
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http://dx.doi.org/10.1002/joa3.12669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8851593PMC
February 2022

Atrial Fibrillation and Dementia: A Report From the AF-SCREEN International Collaboration.

Circulation 2022 02 31;145(5):392-409. Epub 2022 Jan 31.

Department of Community Medicine, UiT The Arctic University of Norway, Tromsø (M.L.L.).

Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.121.055018DOI Listing
February 2022

Updated USPSTF Guidelines for Screening for Atrial Fibrillation: Same as It Ever Was?

JAMA Cardiol 2022 03;7(3):247-249

The Heart Research Institute, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.

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http://dx.doi.org/10.1001/jamacardio.2021.5873DOI Listing
March 2022

Incidence of New Onset Atrial Fibrillation After Cardiovascular Surgery in Vietnam: Results From A Novel Screening Strategy.

J Atr Fibrillation 2021 Aug 31;14(2):20200503. Epub 2021 Aug 31.

Heart Research Institute, Charles Perkins Centre, The University of Sydney, New South Wales, Australia.

Objective: To examine the incidence of atrial fibrillation (AF) newly developed after cardiovascular surgery in Vietnam, its associated risk factors, and postoperative complications. We also sought to evaluate the feasibility of a novel screening strategy for post-operative AF (POAF) using the combination of two portable devices.

Methods: Single-centre, prospective cohort study at the Cardiovascular Centre, E Hospital, Hanoi, Vietnam. All patients aged≥18 years, undergoing cardiovascular surgery and in sinus rhythm preoperatively were eligible. The primary outcome was occurrence of new-onset POAF detected by hand-held single-lead electrocardiography (ECG) or a sphygmomanometer with AF-detection algorithm. Multivariate logistic regression was used to identify risk factors of developing post-operative AF. Feasibility was evaluated by compliance to the protocol and semi-structured interviews.

Results: 112 patients were enrolled between 2018-2019: mean age 52.9±12.2 years; 50.9% female;92.0% (n=103) valve surgery; 9.8% (n=11)coronary surgery. New-onset POAF developed in 49patients (43.8%) with median time to onset 1.27days (IQR 0.96 -2.00 days). Age≥65 years was the only significant risk factor for the development of POAF(OR 3.78, 95% CI 1.16-12.34).The median thromboembolism risk scores (CHA2DS2-VASc score) were comparable among patients with and without POAF (1.0 vs. 1.0, p=0.104). The occurrence of POAF was associated with higher rates of postoperative complications (24.5% vs. 3.2%, p<0.001). Both doctors and nurses found this screening strategy feasible to be implemented long-term with the main difficulties being the instructions on both devices were in English, and an increase in workload.

Conclusions: In this single-centre study, new-onset POAF occurred in 43.8% of patients who underwent cardiovascular surgery. This novel POAF screening strategy was feasible in a low resource setting, and its implementation could be improved by providing continuous training and translation to local language.
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http://dx.doi.org/10.4022/jafib.20200503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8691272PMC
August 2021

High-intensity atrial fibrillation screening to prevent stroke.

Lancet 2021 10 29;398(10310):1465-1467. Epub 2021 Aug 29.

Heart Research Institute, Charles Perkins Centre and Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia.

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http://dx.doi.org/10.1016/S0140-6736(21)01785-2DOI Listing
October 2021

Population screening for atrial fibrillation to prevent stroke.

Lancet 2021 10 29;398(10310):1463-1465. Epub 2021 Aug 29.

Heart Research Institute, Charles Perkins Centre, Sydney, NSW 2006, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Concord Hospital, Concord Clinical School, Sydney, NSW, Australia.

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http://dx.doi.org/10.1016/S0140-6736(21)01750-5DOI Listing
October 2021

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

Thromb Haemost 2022 Feb 16;122(2):286-294. Epub 2021 Aug 16.

Department of Medicine and Therapeutics, Division of Cardiology, Prince of Wales Hospital & Heart & Vascular Institute, The Chinese University of Hong Kong, Hong Kong.

Objective:  We evaluated stroke risk in patients with single time-point screen-detected atrial fibrillation (AF) and the effect of oral anticoagulants (OACs).

Methods:  Consecutive patients aged ≥65 years attending medical outpatient clinics were prospectively enrolled for AF screening using handheld single-lead electrocardiogram (ECG; AliveCor) from December 2014 to December 2017 (NCT02409654). Repeated screening was performed in patients with >1 visit during this period. Three cohorts were formed: screen-detected AF, clinically diagnosed AF, and no AF. Ischemic stroke risk was estimated using adjusted subdistribution hazard ratios (aSHRs) from multivariate regression and no AF as reference, and stratified according to OAC use.

Results:  Of 11,972 subjects enrolled, 2,238 (18.7%) had clinically diagnosed AF at study enrollment. The yield of screen-detected AF on initial screening was 2.3% ( = 223/9,734). AF was clinically diagnosed during follow-up in 2.3% ( = 216/9,440) and during subsequent screening in 71 initially screen-negative patients. Compared with no AF, patients with screen-detected AF without OAC treatment had the highest stroke risk (aSHR: 2.63; 95% confidence interval: 1.46-4.72), while aSHR for clinically diagnosed AF without OAC use was 2.01 (1.54-2.62). Among screen-detected AF, the risk of stroke was significantly less with OAC (no strokes in 196 person-years) compared with those not given OAC (12 strokes in 429 person-years),  = 0.01.

Conclusion:  The prognosis of single time-point ECG screen-detected AF is not benign. The risk of stroke is high enough to warrant OAC use, and reduced by OAC.
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http://dx.doi.org/10.1055/a-1588-8867DOI Listing
February 2022

Refined atrial fibrillation screening and cost-effectiveness in the German population.

Heart 2022 03 10;108(6):451-457. Epub 2021 Aug 10.

University of Sydney, Charles Perkins Centre, Heart Research Institute, Sydney, New South Wales, Australia.

Objective: Little is known on optimal screening population for detecting new atrial fibrillation (AF) in the community. We describe characteristics and estimate cost-effectiveness for a single timepoint electrocardiographic screening.

Methods: We performed a 12-lead ECG in the German population-based Gutenberg Health Study between 2007 and 2012 (n=15 010), mean age 55±11 years, 51% men and collected more than 120 clinical and biomarker variables, including N-terminal pro B-type natriuretic peptide (Nt-proBNP), risk factors, disease symptoms and echocardiographic variables.

Results: Of 15 010 individuals, 466 (3.1%) had AF. New AF was found in 32 individuals, 0.2% of the total sample, 0.5% of individuals aged 65-74 years and predominantly men (86%). The classical risk factor burden was high in individuals with new AF. The median estimated stroke risk was 2.2%/year, while risk of developing heart failure was 21% over 10 years. In the 65-74 year age group, the cost per quality-adjusted life-year gained resulting from a single timepoint screening was €30 361. In simulations, the costs were highly sensitive to AF detection rates, proportion of treatment and type of oral anticoagulant. Prescreening by Nt-proBNP measurements was not cost-effective in the current setting.

Conclusions: In our middle-aged population cohort, we identified 0.2% new AF by single timepoint screening. There was a significant estimated risk of stroke and heart failure in these individuals. Cost-effectiveness for screening may be reached in individuals aged 65 years and older. The simple age cut-off is not improved by using Nt-proBNP as a biomarker to guide a screening programme.
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http://dx.doi.org/10.1136/heartjnl-2020-318882DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8899485PMC
March 2022

Periodontitis induces endothelial dysfunction in mice.

Sci Rep 2021 07 22;11(1):14993. Epub 2021 Jul 22.

Charles Perkins Centre, University of Sydney School of Dentistry, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.

The treatment of periodontitis has numerous positive effects on established chronic health conditions, including cardiovascular disease and diabetes. However, ethical considerations do limit the establishment of human trials to investigate whether periodontitis promotes the early stages of chronic conditions. Therefore, the aim of this study was to investigate whether periodontitis induces endothelial dysfunction in hyperlipidemic apolipoprotein E gene-deficient (ApoE) mice. Forty-five 8-week-old ApoE mice were challenged by oral lavage with Porphyromonas gingivalis and Streptococcus gordonii for 4 weeks. A subgroup of animals (n = 15-17/group) was placed in a metabolic chamber immediately before euthanasia at 4 weeks to measure VO/CO concentrations and voluntary locomotion. In infected and control animals alveolar bone levels were measured by x-ray imaging and endothelial function was determined by measuring endothelial-dependent vasorelaxation of aortic rings. The mRNA expression levels of serum amyloid A and tumor necrosis factor were determined in liver tissues by qRT PCR and protein concentrations in serum by ELISA. Caecal contents were analysed by sequencing to determine changes to the gut microbiota to investigate linkages between microbiome and systemic changes. The results showed that oral lavage of P. gingivalis and S. gordonii for 4 weeks, initiated periodontitis in ApoE mice, similar to the human situation. The oral inflammation was accompanied by a significant increase in mRNA expression of pro-inflammatory mediators serum amyloid A1 and tumor necrosis factor in the liver. Mice with periodontitis also exhibited impaired endothelial-dependent vasorelaxation responses to acetylcholine. This systemic response was connected to increased energy expenditure, locomotion and respiratory quotient. No differences were detected in caecal microbiota between the infected and control animals. Overall, this is the first report that provide evidence that periodontitis induces endothelial dysfunction in mice. Other systemic responses observed in response to the local reaction need further investigation. The study suggests that early prevention of periodontitis may help limit the early stages of endothelial dysfunction that is linked to atherogenesis in humans.
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http://dx.doi.org/10.1038/s41598-021-94418-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8298548PMC
July 2021

World Heart Federation Roadmap on Atrial Fibrillation - A 2020 Update.

Glob Heart 2021 05 27;16(1):41. Epub 2021 May 27.

Universidad de Buenos Aires, AR.

The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world's population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great.
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http://dx.doi.org/10.5334/gh.1023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8162289PMC
May 2021

Risk of Ischemic Stroke in Asymptomatic Atrial Fibrillation Incidentally Detected in Primary Care Compared with Other Clinical Presentations.

Thromb Haemost 2022 Feb 30;122(2):277-285. Epub 2021 Jun 30.

Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, Australia.

Background:  It is uncertain whether stroke risk of asymptomatic ambulatory atrial fibrillation (AA-AF) incidentally detected in primary care is comparable with other clinical AF presentations in primary care or hospital.

Methods:  The stoke risk of 22,035 patients with incident nonvalvular AF from the United Kingdom primary care Clinical Practice Research Datalink with linkage to hospitalization and mortality data was compared with 23,605 controls without AF (age- and sex-matched 5:1 to 5,409 AA-AF patients). Incident AF included 5,913 with symptomatic ambulatory AF (SA-AF); 4,989 with primary and 5,724 with nonprimary hospital AF discharge diagnosis (PH-AF and non-PH-AF); and 5,409 with AA-AF. Ischemic stroke adjusted subhazard ratios (aSHRs) within 3 years of AA-AF were compared with SA-AF, PH-AF, non-PH-AF, and no AF, accounting for mortality as competing risk and adjusted for ischemic stroke risk factors.

Results:  There were 1,026 ischemic strokes in 49,544 person-years in patients with incident AF (crude incidence rate: 2.1 ischemic strokes/100 person-years). Ischemic stroke aSHR over 3 years showed no differences between AA-AF and SA-AF, PH-AF, and non-PH-AF groups (aSHR: 0.87-1.01 vs. AA-AF). All AF groups showed a significantly higher aSHR compared with no AF.

Conclusion:  Ischemic stroke risk in patients with AA-AF incidentally detected in primary care is far from benign, and not less than incident AF presenting clinically in general practice or hospital. This provides justification for identification of previously undetected AF, e.g., by opportunistic screening, and subsequent stroke prevention with thromboprophylaxis, to reduce the approximately 10% of ischemic strokes related to unrecognized AF.
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http://dx.doi.org/10.1055/a-1541-3885DOI Listing
February 2022

Searching for atrial fibrillation post-stroke with prolonged monitoring: Do it early, but should we be looking for something else?

Int J Cardiol Heart Vasc 2021 Jun 9;34:100819. Epub 2021 Jun 9.

Heart Research Institute, Charles Perkins Centre, Sydney, Australia.

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http://dx.doi.org/10.1016/j.ijcha.2021.100819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207213PMC
June 2021

Subclinical Atrial Fibrillation and the Risk of Recurrent Ischemic Stroke.

Thromb Haemost 2021 06 21;121(6):697-699. Epub 2021 May 21.

Heart Research Institute, Charles Perkins Centre, University of Sydney, Camperdown, Sydney, NSW, Australia.

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http://dx.doi.org/10.1055/s-0041-1726403DOI Listing
June 2021

Stroke Risk in Adults With Atrial Fibrillation According to Sex.

Heart Lung Circ 2021 Jul 22;30(7):937-938. Epub 2021 Apr 22.

Heart Research Institute, Sydney, NSW, Australia; Charles Perkins Centre and Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.

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http://dx.doi.org/10.1016/j.hlc.2021.04.006DOI Listing
July 2021

Screening for Atrial Fibrillation in American Indian Adults in a Tribal Primary Care Clinic.

J Am Heart Assoc 2021 05 21;10(9):e020069. Epub 2021 Apr 21.

Heart Research Institute Charles Perkins Centre University of Sydney Australia.

Background American Indian adults have a higher risk of atrial fibrillation (AF) compared with other racial groups. We implemented opportunistic screening to detect silent AF in American Indian adults attending a tribal health system using a mobile, single-lead ECG device. Methods and Results American Indian patients aged ≥50 years followed in a tribal primary care clinic with no history of AF underwent a 30-second ECG. A cardiologist overread all tracings to confirm the diagnosis of AF. After AF was confirmed, patients were referred to their primary care physician for initiation of anticoagulation. Patients seen over the same time period, who were not undergoing screening, served as controls. A total of 1019 patients received AF screening (mean age, 61.5±8.9 years, 62% women). Age and sex distribution of those screened was similar to the overall clinic population. New AF was diagnosed in 15 of 1019 (1.5%) patients screened versus 4 of 1267 (0.3%) patients who were not screened (mean difference, 1.2%; 95% CI, 0.3%-2.2%, =0.002). Eight of 15 with new screen-detected AF were aged <65 years. Those with screen-detected AF were slightly older and had a higher CHADS-VASc score than those without AF. Fourteen of 15 patients diagnosed with new AF had a CHADS-VASc score ≥1 and initiated anticoagulation. Conclusions Opportunistic, mobile single-lead ECG screening for AF is feasible in tribal clinics, and detects more AF than usual care, leading to appropriate initiation of anticoagulation. AF develops at a younger age in American Indian adults who would likely benefit from earlier AF screening. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03740477.
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http://dx.doi.org/10.1161/JAHA.120.020069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8200768PMC
May 2021

Decoding stroke risk scores in atrial fibrillation: still more work to do.

Eur Heart J 2021 04;42(15):1486-1488

Cardiology Department, Concord Repatriation General Hospital, Sydney, Australia.

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http://dx.doi.org/10.1093/eurheartj/ehaa1111DOI Listing
April 2021

Response to letter to the editor regarding: "Atrial fibrillation prevalence and risk profile from novel community-based screening in Thailand: A prospective multi-centre study".

Int J Cardiol Heart Vasc 2021 Apr 19;33:100752. Epub 2021 Mar 19.

Heart Research Institute, Sydney Australia, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.

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http://dx.doi.org/10.1016/j.ijcha.2021.100752DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8010615PMC
April 2021

Clinical Factors Associated with Atrial Fibrillation Detection on Single-Time Point Screening Using a Hand-Held Single-Lead ECG Device.

J Clin Med 2021 Feb 12;10(4). Epub 2021 Feb 12.

Heart Research Institute, Charles Perkins Centre, and Concord Hospital Cardiology, University of Sydney, Sydney 2006, Australia.

Our aim was to assess the prevalence of unknown atrial fibrillation (AF) among adults during single-time point rhythm screening performed during meetings or social recreational activities organized by patient groups or volunteers. A total of 2814 subjects (median age 68 years) underwent AF screening by a handheld single-lead ECG device (MyDiagnostick). Overall, 56 subjects (2.0%) were diagnosed with AF, as a result of 12-lead ECG following a positive/suspected recording. Screening identified AF in 2.9% of the subjects ≥ 65 years. None of the 265 subjects aged below 50 years was found positive at AF screening. Risk stratification for unknown AF based on a CHADSVASc > 0 in males and >1 in females (or CHADSVA > 0) had a high sensitivity (98.2%) and a high negative predictive value (99.8%) for AF detection. A slightly lower sensitivity (96.4%) was achieved by using age ≥ 65 years as a risk stratifier. Conversely, raising the threshold at ≥75 years showed a low sensitivity. Within the subset of subjects aged ≥ 65 a CHADSVASc > 1 in males and >2 in females, or a CHADSVA > 1 had a high sensitivity (94.4%) and negative predictive value (99.3%), while age ≥ 75 was associated with a marked drop in sensitivity for AF detection.
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http://dx.doi.org/10.3390/jcm10040729DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7917757PMC
February 2021

Atrial fibrillation: villain or bystander in vascular brain injury.

Eur Heart J Suppl 2020 Nov 6;22(Suppl M):M51-M59. Epub 2020 Dec 6.

University Heart and Vascular Centre, Department of Cardiology, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK e.V.), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.

Atrial fibrillation (AF) and stroke are inextricably connected, with classical Virchow pathophysiology explaining thromboembolism through blood stasis in the fibrillating left atrium. This conceptualization has been reinforced by the remarkable efficacy of oral anticoagulant (OAC) for stroke prevention in AF. A number of observations showing that the presence of AF is neither necessary nor sufficient for stroke, cast doubt on the causal role of AF as a villain in vascular brain injury (VBI). The requirement for additional risk factors before AF increases stroke risk; temporal disconnect of AF from a stroke in patients with no AF for months before stroke during continuous ECG monitoring but manifesting AF only after stroke; and increasing recognition of the role of atrial cardiomyopathy and atrial substrate in AF-related stroke, and also stroke without AF, have led to rethinking the pathogenetic model of cardioembolic stroke. This is quite separate from recognition that in AF, shared cardiovascular risk factors can lead both to non-embolic stroke, or emboli from the aorta and carotid arteries. Meanwhile, VBI is now expanded to include dementia and cognitive decline: research is required to see if reduced by OAC. A changed conceptual model with less focus on the arrhythmia, and more on atrial substrate/cardiomyopathy causing VBI both in the presence or absence of AF, is required to allow us to better prevent AF-related VBI. It could direct focus towards prevention of the atrial cardiomyopathy though much work is required to better define this entity before the balance between AF as villain or bystander can be determined.
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http://dx.doi.org/10.1093/eurheartj/suaa166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916423PMC
November 2020

Next frontier in management of atrial fibrillation.

Heart 2021 05 23;107(9):767-768. Epub 2021 Feb 23.

Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia

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http://dx.doi.org/10.1136/heartjnl-2021-318961DOI Listing
May 2021

Clinical Outcomes in Asymptomatic and Symptomatic Atrial Fibrillation Presentations in GARFIELD-AF: Implications for AF Screening.

Am J Med 2021 07 16;134(7):893-901.e11. Epub 2021 Feb 16.

Thrombosis Research Institute, London, UK; University College London, London, UK.

Background: Asymptomatic atrial fibrillation is often detected incidentally. Prognosis and optimal therapy for asymptomatic compared with symptomatic atrial fibrillation is uncertain. This study compares clinical characteristics, treatment, and 2-year outcomes of asymptomatic and symptomatic atrial fibrillation presentations.

Methods: Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD-AF) is a global, prospective, observational study of newly diagnosed atrial fibrillation with ≥1 stroke risk factors (http://www.clinicaltrials.gov, unique identifier: NCT01090362). Patients were characterized by atrial fibrillation-related symptoms at presentation and the CHADS-VASc score. Two-year follow-up recorded anticoagulation patterns (vitamin K antagonist, direct oral anticoagulants, parenteral therapy) and outcomes (stroke/systemic embolism, all-cause mortality, and bleeding).

Results: At presentation, of 52,032 eligible patients, 25.4% were asymptomatic and 74.6% symptomatic. Asymptomatic patients were slightly older (72 vs 70 years), more often male (64.2% vs 52.9%), and more frequently initiated on anticoagulation ± antiplatelets (69.4% vs 66.0%). No difference in events (adjusted hazard ratios, 95% confidence interval) for nonhemorrhagic stroke/systemic embolism (1.19, 0.97-1.45), all-cause mortality (1.06, 0.94-1.20), or bleeding (1.02, 0.87-1.19) was observed. Anticoagulation was associated with comparable reduction in nonhemorrhagic stroke/systemic embolism (0.59, 0.43-0.82 vs 0.78, 0.65-0.93) and all-cause mortality (0.69, 0.59-0.81 vs 0.77, 0.71-0.85) in asymptomatic versus symptomatic, respectively.

Conclusions: Major outcomes do not differ between asymptomatic and symptomatic atrial fibrillation presentations and are comparably reduced by anticoagulation. Opportunistic screening-detected asymptomatic atrial fibrillation likely has the same prognosis as asymptomatic atrial fibrillation at presentation and likely responds similarly to anticoagulation thromboprophylaxis.
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http://dx.doi.org/10.1016/j.amjmed.2021.01.017DOI Listing
July 2021

Research Priorities in Atrial Fibrillation Screening: A Report From a National Heart, Lung, and Blood Institute Virtual Workshop.

Circulation 2021 01 25;143(4):372-388. Epub 2021 Jan 25.

Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., J.P.P., S.M.A.-K.).

Clinically recognized atrial fibrillation (AF) is associated with higher risk of complications, including ischemic stroke, cognitive decline, heart failure, myocardial infarction, and death. It is increasingly recognized that AF frequently is undetected until complications such as stroke or heart failure occur. Hence, the public and clinicians have an intense interest in detecting AF earlier. However, the most appropriate strategies to detect undiagnosed AF (sometimes referred to as subclinical AF) and the prognostic and therapeutic implications of AF detected by screening are uncertain. Our report summarizes the National Heart, Lung, and Blood Institute's virtual workshop focused on identifying key research priorities related to AF screening. Global experts reviewed major knowledge gaps and identified critical research priorities in the following areas: (1) role of opportunistic screening; (2) AF as a risk factor, risk marker, or both; (3) relationship between AF burden detected with long-term monitoring and outcomes/treatments; (4) designs of potential randomized trials of systematic AF screening with clinically relevant outcomes; and (5) role of AF screening after ischemic stroke. Our report aims to inform and catalyze AF screening research that will advance innovative, resource-efficient, and clinically relevant studies in diverse populations to improve the diagnosis, management, and prognosis of patients with undiagnosed AF.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.047633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8776506PMC
January 2021

Atrial fibrillation prevalence and risk profile from novel community-based screening in Thailand: A prospective multi-centre study.

Int J Cardiol Heart Vasc 2021 Feb 12;32:100709. Epub 2021 Jan 12.

Heart Research Institute, Sydney Australia.

Background: In Thailand, almost one-quarter of strokes are related to atrial fibrillation (AF), and many could be prevented if AF were diagnosed and treated prior to the stroke. Therefore, we tested a novel strategy to screen large numbers of community residents using village health volunteers and primary care nurses.

Methods: Local primary care nurses and village health volunteers in Phetchaburi and Lopburi provinces, Thailand were trained to perform AF screening using a blood pressure device with AF algorithm (Microlife A200 AFib). 10% of residents aged ≥ 65 years were randomly selected for screening during home-visits. Participants with possible AF were given follow-up appointments for further testing, including 12-lead ECG and echocardiogram.

Results: Over two-months, 9.7% (13,864/143,478) of the target population were screened: mean age 73.2 ± 6.4 years, 32.4% male. The estimated AF prevalence (detected by Microlife A200 AFib) was 2.8% (95% CI, 2.6-3.1%) for age ≥ 65 years (i.e. 393/13,864 participants). Prevalence increased with age from 1.9% (65-69 years) to 5.0% (≥85 years) (p < 0.001). Only 58% (226/393) of participants with suspected AF attended the follow-up appointment (1-3 months after initial screen): mean CHA2DS2-VASc score 3.2 ± 1.2; 86.3% (195/226) had Class-1 oral anticoagulation recommendation, and 33% (75/226) had AF on 12-lead ECG.

Conclusions: In Thailand, large-scale AF screening in the community is feasible using trained volunteer health workers, allowing screening of large numbers in a short time-period. Further investigation of this strategy is warranted, ensuring mechanisms to obtain a timely rhythm strip or 12-lead ECG locally, and a designated pathway to treatment.
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http://dx.doi.org/10.1016/j.ijcha.2020.100709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811109PMC
February 2021

Atrial fibrillation self screening, management and guideline recommended therapy (AF SELF SMART): A protocol for atrial fibrillation self-screening in general practice.

Int J Cardiol Heart Vasc 2021 Feb 16;32:100683. Epub 2020 Dec 16.

Sydney Medical School and Charles Perkins Centre, University of Sydney, Sydney, Australia.

Background: Opportunistic screening for silent atrial fibrillation (AF) is recommended to reduce stroke, but screening rates are sub-optimal in general practice. We hypothesize that patient self-screening in the waiting room may improve screening and detection of AF.

Methods And Analyses: This proof-of-concept study tests a purpose-designed AF self-screening station and customised software which seamlessly integrates with general practice electronic medical records and workflow. The self-screening station records a lead-1 ECG. The software automatically (1) identifies eligible patients (aged ≥65 years, no AF diagnosis) from the practice appointment diary; (2) sends eligible patients an automated SMS reminder prior to their appointment; (3) creates individualised QR code to scan at self-screening station; and (4) imports the ECG and result directly into the patients' electronic medical record. Between 5 and 8 general practices in New South Wales, Australia, will participate with an aim of 1500 patients undertaking self-screening. The main outcome measures will be the proportion of eligible patients that undertook self-screening, incidence of newly-diagnosed AF, and patient and staff experience of the self-screening process. De-identified data will be collected using a clinical audit tool, and qualitative interviews will determine patient and staff acceptability.

Ethics And Dissemination: Ethics approval was received from the University of Sydney Human Research Ethics Committee in June 2019 (Project no: 2019/382) and the University of Notre Dame Human Research Ethics Committee (Project no: 019145S) in October 2019. Results will be disseminated through various forums, including peer-reviewed publication and conference presentations.ACTRN12620000233921.
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http://dx.doi.org/10.1016/j.ijcha.2020.100683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7750156PMC
February 2021

Next frontier for stroke prevention in atrial fibrillation: ensuring anticoagulant persistence.

Heart 2020 Dec 23. Epub 2020 Dec 23.

Heart Research Institute, Sydney, NSW, Australia

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http://dx.doi.org/10.1136/heartjnl-2020-318392DOI Listing
December 2020

Nurse Led Smartphone Electrographic Monitoring for Atrial Fibrillation after Ischemic Stroke: SPOT-AF.

J Stroke 2020 Sep 29;22(3):387-395. Epub 2020 Sep 29.

Heart Research Institute Charles Perkins Centre, and Concord Hospital Cardiology, University of Sydney, Sydney, Australia.

Background And Purpose: Paroxysmal atrial fibrillation (PAF) underlying acute stroke frequently evades detection by standard practice, considered to be a combination of routine electrocardiogram (ECG) monitoring, and 24-hour Holter recordings. We hypothesized that nurse-led in-hospital intermittent monitoring approach would increase PAF detection rate.

Methods: We recruited patients hospitalised for stroke/transient ischemic attack, without history of atrial fibrillation (AF), in a prospective multi-centre observational study. Patients were monitored using a smartphone-enabled handheld ECG (iECG) during routine nursing observations, and underwent 24-hour Holter monitoring according to local practice. The primary outcome was comparison of AF detection by nurse-led iECG versus Holter monitoring in patients who received both tests: secondary outcome was oral anticoagulant commencement at 3-month following PAF detection.

Results: One thousand and seventy-nine patients underwent iECG monitoring: 294 had iECG and Holter monitoring. AF was detected in 25/294 (8.5%) by iECG, and 8/294 (2.8%) by 24-hour Holter recordings (P<0.001). Median duration from stroke onset to AF detection for iECG was 3 days (interquartile range [IQR], 2 to 6) compared with 7 days (IQR, 6 to 10) for Holter recordings (P=0.02). Of 25 patients with AF detected by iECG, 11 were commenced on oral anticoagulant, compared to 5/8 for Holter. AF was detected in 8.8% (69/785 patients) who underwent iECG recordings only (P=0.8 vs. those who had both iECG and 24-hour Holter).

Conclusions: Nurse-led in-hospital iECG surveillance after stroke is feasible and effective and detects more PAF earlier and more frequently than routine 24-hour Holter recordings. Screening with iECG could be incorporated into routine post-stroke nursing observations to increase diagnosis of PAF, and facilitate institution of guideline-recommended anticoagulation.
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http://dx.doi.org/10.5853/jos.2020.00689DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568969PMC
September 2020
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