Over recent years there has been significant improvements in the detection and treatment of atrial fibrillation (AF) – leading to a reduction in AF-related strokes, fewer deaths and financial savings to the NHS and social care. However, this progress may be halted or even eroded by the current COVID-19 pandemic. During a three-week period of lock down in Denmark there was a 47% reduction in the diagnosis of new AF.1 A UK study reported a 43% reduction in the rate of diagnosis of cardiovascular (CV) conditions during the first three months of the pandemic.2 The same study also reported a 29-52% reduction in first prescriptions of CV medications over the same time period. The reasons for this are likely to be multifactorial but the consequences will be significant – as detection and treatment rates fall; the number of AF-related strokes and associated deaths, will increase.
Opportunities for detection
AF is often detected opportunistically when clinicians put fingers on a patient’s pulse and identify an irregularity in the heart rhythm. This is usually followed by a 12 lead ECG to confirm the diagnosis. The opportunities for detection have reduced dramatically as face to face contact is being avoided to minimise infection risks, with many consultations moving to telephone or video formats.
So, what measures can be taken to fill this gap? Public awareness of AF is important. Each year the need to ‘Know Your Pulse’ is promoted by the AF Association with resources to support patients to check their own pulse rate and rhythm. Pulse checks should also be embedded in routine reviews of long-term conditions such as hypertension, coronary heart disease and diabetes; whether these are delivered remotely, with coaching provided by health care assistants or other trained staff to talk patients through the pulse check process and answer any questions they may have; or in face to face consultations.
Closing the gap with technology
New technologies may help to close the detection gap. For example, Fibricheck uses a smartphone camera and flash to undertake pulse wave analysis of the fingertip and identify possible AF. If access to 12 lead ECGs is restricted, mobile ECG devices such as Kardia by AliveCor (six lead) or MyDiagnostick (single lead), may be of value to confirm a diagnosis and allow early initiation of anticoagulant therapy, with a 12-lead ECG recorded when access becomes more readily available.
Innovative solutions to maintain patient safety
The timely initiation of anticoagulation is essential to reduce the risk that patients with AF and one or more additional risk factors will experience an AF-related stroke. From a quality and safety perspective, we must maintain continuity of care for people prescribed warfarin, requiring INR (international normalised ratio) checks, or direct oral anticoagulants (DOACs), requiring renal monitoring.
Anticoagulation services have faced a number of challenges to maintain safe and effective services. Patients themselves have, in some cases, been concerned about accessing monitoring of their anticoagulant therapy due to fears regarding the risk of infection. To address this, a number of measures have been taken. Many services have moved to direct oral anticoagulants rather than warfarin to minimise the monitoring burden. Innovative solutions have been introduced to minimise infection risk, such as drive-through INR services, and increasing the use of patient self-testing of INR with Coaguchek® where appropriate.
Going forward in the context of COVID-19
The latest data has revealed significant gains made over the last four years in improving the detection and treatment of AF around the country. As the impact of COVID threatens to stifle these gains, it is important that AF remains on the agenda for frontline practitioners. AHSNs have been actively working with local primary care teams to support the delivery of CVD prevention during the pandemic. This guide from Oxford AHSN shares good practice examples and useful resources that teams can draw on to support practice in all areas of CVD prevention. As we move forward, we must continue to work together, sharing new and innovative ways of working to prevent strokes and save lives.