Background: Atrial fibrillation (AF) is a prevalent cardiac arrhythmia linked with a five-fold increased risk of ischaemic stroke. Despite the need for pulse rhythm checks of reasonable duration in selectively identified high-risk patients, the NHS is under pressure to perform these tasks to prevent stroke during daily practice in primary care.
Purpose: This program aimed to establish an end-to-end pathway to identify, detect, diagnose, and manage high-risk patients with no prior AF diagnosis.
Methods: The AF Stroke Prevention Hub program was aimed at patients aged 65 and above with a history of heart failure or stroke/transient ischaemic attack. Data from electronic patient records identified these patients, while exclusion criteria consisted of known AF, implanted cardiac devices, end-stage renal disease, and end-of-life care. The program used a medically certified photoplethysmography (PPG) smartphone application to monitor the heart rate and rhythm and track symptoms using photoplethysmography. Patients were facilitated to perform two measurements per day for 7 days, and additional measurements if experiencing symptoms. Those who were digitally excluded were offered an assessment in a face-to-face clinic appointment. Based on the PPG recordings, patients with a positive finding received a confirmatory ECG examination and anticoagulation therapy, once the diagnosis was established, within 48 hours. Those with a negative result based on the PPG monitoring period received reassurance and advice.
Results: Between February 2022 and February 2023, after applying inclusion and exclusion criteria, 669 patients were found to be eligible, from 4 primary care practices. Two hundred and sixty-seven patients were issued PPG applications after obtaining consent. In total, 210 patients completed the PPG-based, 7-day monitoring period. The technology adoption rate was 78.65% in this group of patients.
A total of 10 patients (6.5%) were detected with possible AF based on the PPG recordings. Six patients were diagnosed based on a confirmatory 12-lead ECG or a 7-day Holter. All patients with newly diagnosed AF (3.9%) received anticoagulation therapy and were managed accordingly, while the remaining patients received advice regarding self-management, lifestyle and yearly health checks.
Among the high-risk group of cardiac failure, 4 patients were detected with possible AF, based on the PPG recordings. All 4 were confirmed via a 12-lead ECG or a Holter monitor, with an AF detection rate of 9.09%. Combining all stratified risk patient cohorts, 10 (4.76%) were detected with possible AF based on the PPG recordings and 6 (2.8%) were verified based on a confirmatory 12-lead ECG or a 7-day Holter.
Conclusion: Compared with the current NHS opportunistic pulse check where the detection rate is <1%, the AF Stroke Prevention Hub program successfully identified patients with a significantly higher detection rate. The hub delivered an end-to-end pathway allowing real-time reporting and triaging of patients, early detection, appropriate confirmation and rapid treatment with favourable real-life technology adoption. Expanding the data-driven program to a wider difficult-to-reach population could reduce the burden on NHS and improve patient outcomes. ❑
