Rhys G C, Azhar M F, Foster A
Keele University, Staffordshire ST5 5BG, UK.
Qual Prim Care. 2013;21(2):131-40.
Atrial fibrillation (AF) is a common, treatable cause of stroke. Screening is recommended at influenza vaccination ('flu') clinics, but not implemented nationally.
We aimed to determine if screening for AF by pulse assessment of those aged ≥ 65 years attending flu vaccination is effective, practical and feasible. The success of screening was determined by discovery of undiagnosed cases, estimating the prevalence of undiagnosed AF, assessing the accuracy of a second-year General Practice Specialty Trainee (GPST2) and interpretative software at diagnosing AF on electrocardiography (ECG), completion without disrupting routine practice, estimating cost-effectiveness and guiding future screening.
Patients ≥ 65 years old attending flu clinics were screened. Patients with an irregular pulse had an ECG, with interpretation by the GPST2, interpretative automated software and a reporting service.
A total of 573 patients were screened, identifying 95 patients with an irregular pulse: 21 had prior AF, 5 were < 65 years old and 1 had a previous myocardial infarction (MI); 68 were invited for ECG, of whom 39 attended; 2 new cases of AF were diagnosed. Pre-screening AF prevalence was 12.2% in those aged ≥ 75 years, and 12.4% after screening. A new case was discovered for every 286 patients screened. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 100% for the GPST2 and interpretative software for ECG diagnosis of AF versus cardiological assessment. Identifying a new case cost approximately £234. Limitations included low uptake of ECG appointments, and delayed and low completion of ECGs, leading to missed AF diagnoses.
Screening was ineffective. ECG immediately after pulse assessment is essential. Screening was acceptable to patients but required additional resources. Age groups 65-74 and ≥ 85 years were not adequately screened using flu clinics. Novel methods screening older, non-attending patients are required. Practices should introduce annual pulse checks into chronic disease templates and prompts for those aged ≥ 65 years attending surgery. Additional screening should target practices with low AF prevalence or poor rates of opportunistic screening.
心房颤动（AF）是一种常见的、可治疗的中风病因。建议在流感疫苗接种诊所进行筛查，但尚未在全国范围内实施。
我们旨在确定对65岁及以上前来接种流感疫苗的人群进行脉搏评估筛查房颤是否有效、实用和可行。筛查的成功与否取决于未诊断病例的发现、未诊断房颤患病率的估计、第二年全科医学专科培训生（GPST2）和解读软件对心电图（ECG）诊断房颤的准确性评估、在不干扰常规诊疗的情况下完成筛查、成本效益估计以及为未来筛查提供指导。
对65岁及以上前来流感诊所的患者进行筛查。脉搏不规则的患者进行心电图检查，并由GPST2、解读自动化软件和报告服务进行解读。
共筛查了573例患者，发现95例脉搏不规则的患者：21例有既往房颤病史，5例年龄小于65岁，1例有既往心肌梗死（MI）；68例被邀请进行心电图检查，其中39例接受了检查；诊断出2例新发房颤病例。75岁及以上人群筛查前房颤患病率为12.2%，筛查后为12.4%。每筛查286例患者发现1例新病例。与心脏科评估相比，GPST2和解读软件对心电图诊断房颤的敏感性、特异性、阳性预测值（PPV）和阴性预测值（NPV）均为100%。发现1例新病例的成本约为234英镑。局限性包括心电图检查预约的接受率低、心电图检查延迟且完成率低，导致房颤诊断遗漏。
筛查无效。脉搏评估后立即进行心电图检查至关重要。筛查对患者来说是可以接受的，但需要额外的资源。使用流感诊所对65 - 74岁和85岁及以上年龄组进行的筛查不充分。需要采用新的方法筛查年龄较大、未就诊的患者。医疗机构应将年度脉搏检查纳入慢性病模板，并为65岁及以上前来就诊的患者提供提示。额外的筛查应针对房颤患病率低或机会性筛查率低的医疗机构。
