Centre for Health and Social Change, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Farr Institute of Health Informatics Research, University College London, London, United Kingdom.
Glob Heart. 2017 Dec;12(4):273-284. doi: 10.1016/j.gheart.2017.01.015. Epub 2017 Mar 21.
The World Heart Federation has undertaken an initiative to develop a series of Roadmaps to promote development of national policies and health systems approaches, and to identify potential roadblocks on the road to effective prevention, detection, and management of cardiovascular disease in low-and middle-income countries (LMICs) and develop strategies for overcoming these. This Roadmap focuses on atrial fibrillation (AF). AF is the most common, clinically significant arrhythmia and, among other clinical outcomes, is associated with increased risk of stroke.
Development of this Roadmap included a review of published guidelines and research papers, and consultation with an expert committee comprising experts in clinical management of AF and health systems research in LMICs. The Roadmap identifies 1) key interventions for detection, diagnosis, and management of AF; 2) gaps in implementation of these interventions (knowledge-practice gaps); 3) health system roadblocks to implementation of AF interventions in LMICs; and 4) potential strategies for overcoming these.
More research is needed on determinants and primary prevention of AF. Knowledge-practice gaps for detection, diagnosis, and management of AF are present worldwide, but may be more prominent in LMICs. Potential barriers to implementation of AF interventions include long distances to health facilities, shortage of health care professionals with training in AF, including interpretation of ECG, unaffordability of oral anticoagulants for patient households, reluctance on the part of physicians to initiate oral anticoagulant (OAC) therapy, and lack of awareness of the importance of persistent adherence to OAC therapy. Potential solutions include training of nonphysician health workers and pharmacists in pulse-taking, use of telemedicine technologies to transmit electrocardiogram results, engagement of nonphysician health workers in OAC therapy adherence support, and country-specific support and education programs for noncardiologist health care professionals.
AF affects millions of people worldwide and, left untreated, increases the risk and severity of stroke and heart failure. Although guidelines for the detection, diagnosis, and management of AF exist, there are gaps in implementation of these guidelines globally, and in particular in LMICs. This Roadmap identifies some potential solutions that may improve AF outcomes in LMICs but require further evaluation in these settings.
世界心脏联合会开展了一项计划，旨在制定一系列路线图，以促进发展国家政策和卫生系统方法，并确定在中低收入国家（LMICs）有效预防、检测和管理心血管疾病的道路上的潜在障碍，并制定克服这些障碍的策略。本路线图侧重于心房颤动（AF）。AF 是最常见的、具有临床意义的心律失常，除了其他临床结果外，还与中风风险增加有关。
本路线图的制定包括审查已发表的指南和研究论文，并咨询由 AF 临床管理和 LMICs 卫生系统研究专家组成的专家委员会。该路线图确定了 1）AF 的检测、诊断和管理的关键干预措施；2）这些干预措施实施中的差距（知识-实践差距）；3）LMICs 中实施 AF 干预措施的卫生系统障碍；以及 4）克服这些障碍的潜在策略。
需要更多关于 AF 的决定因素和一级预防的研究。全球范围内存在 AF 的检测、诊断和管理知识-实践差距，但在 LMICs 中可能更为突出。实施 AF 干预措施的潜在障碍包括距离卫生机构较远、缺乏经过 AF 培训的卫生保健专业人员，包括心电图解读、患者家庭负担不起口服抗凝剂、医生不愿开始口服抗凝剂（OAC）治疗以及缺乏对坚持 OAC 治疗重要性的认识。潜在的解决方案包括培训非医师卫生工作者和药剂师进行脉搏检查、使用远程医疗技术传输心电图结果、让非医师卫生工作者参与 OAC 治疗依从性支持以及为非心脏病专家卫生保健专业人员制定国家特定的支持和教育计划。
AF 影响着全球数百万人，如果不进行治疗，会增加中风和心力衰竭的风险和严重程度。尽管存在 AF 的检测、诊断和管理指南，但在全球范围内，特别是在 LMICs 中，这些指南的实施存在差距。本路线图确定了一些可能改善 LMICs 中 AF 结果的潜在解决方案，但需要在这些环境中进一步评估。
