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Why should I look for undiagnosed atrial fibrillation?
I have had an interest in atrial fibrillation (AF) since I was a PharmD student. I have had the opportunity to provide direct patient care to patients with AF and to conduct clinical research to evaluate strategies for both prevention and treatment of AF. Through these experiences, I have developed an appreciation for the importance of rapidly identifying the most optimal medication regimens for patients with AF. Approximately 20% of high-risk individuals likely have AF that has not been diagnosed. Undiagnosed AF is often first discovered when a patient presents with stroke. Approximately 5 – 7% of patients with undiagnosed AF develop a stroke. It would be ideal to identify AF before stroke can develop.
What can I do to help find undiagnosed atrial fibrillation?
The best way pharmacists can help find undiagnosed AF is through opportunistic screening. Opportunistic screening is screening for AF when a patient is seeing a pharmacist for something else (i.e., diabetes, hypertension). Opportunistic screening is recommended for patients older than 65 years by European and Australian guidelines.1,2 However, United States guidelines suggest that clinical judgement should be used in deciding whether to screen for AF.3 Screening methods can include digital pulse palpation, newer technologies like smart phone apps and devices that obtain single lead electrocardiograms (ECG), or a standard 12-lead ECG. In one study, 6.5% of screened patients who presented to the pharmacist for flu vaccination, were identified to have potential undiagnosed AF.
Who should I screen for atrial fibrillation?
Only about 1 – 2% of patients screened will ultimately be newly diagnosed with AF. Therefore, it is important to screen the most likely patients. High risk patients include those with hypertension, diabetes, heart failure and of older age. A simple strategy for identifying patients to screen could be to calculate a CHA2DS2 – VASc score and screen anyone with a score > 2 or 3.
How should I screen patients for atrial fibrillation?
When planning a screening program, it is important to consider where screening will fit best into your interactions with patients. Identifying an appropriate location in the clinic or pharmacy to conduct screening is important. Identifying the screening method that will be used is also critical to the plan. A final important consideration is to plan what will happen when you find a patient who screens positive for atrial fibrillation. It would be helpful to decide how you will collaborate with a physician or other healthcare professional to confirm screen identified potential AF. This could include the development of a protocol for obtaining a confirmatory 12-lead ECG or a standard referral process to a physician or mid-level provider. It is important to work these details out before you identify your first patient who may have undiagnosed AF.
Pharmacists have a great opportunity to help patients avoid the potentially devastating consequences of undiagnosed AF. Simple, inexpensive methods can be used to identify patients with potential AF in routine pharmacists’ practice. Development of an opportunistic screening program is a great way for pharmacists to ensure that patients are receiving optimal medications for all chronic conditions.
- Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2020;42:373-498
- Brierger D, Amerena J, Bajorek B, et al. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018. Heart, Lung and Circ 2018;27:1209-66.
- US Preventive Services Task Force. Screening for atrial fibrillation. US Preventive Services Task Force recommendation statement. JAMA 2022;327:360-367