AF Association News & Events
EHRA 2021: Key studies for healthcare professionals
The European Heart Rhythm Association (EHRA) annual meeting ran online from 23rd to 25th April (with all content available on-demand to registered users until 24th May) and explored all aspects of arrhythmia management. In this report, we explore the key findings presented at the congress.
STROKESTOP shows small clinical benefit with systematic screen for AF in people aged 75 plus
TCTMD reports that a population-based programme for detecting atrial fibrillation (AF) improved clinical outcomes in 75- and 76-year-olds. In the randomised STROKESTOP, presented at EHRA by Dr Emma Svennberg (Karolinska Institutet, Stockholm, Sweden), 13,979 people were invited for screening and 13,996 were not (mean age 76 years; 55% women). In the screening group, those without a prior diagnosis of AF underwent intermittent ECG recordings twice daily for two weeks. Systematic follow-up was arranged for patients with newly detected AF and those with a pre-existing diagnosis who were not yet treated with oral anticoagulation.
Over more than five years of follow-up, according to TCTMD, risk of the combined primary endpoint of ischaemic stroke, systemic thromboembolism, all-cause mortality, haemorrhagic stroke, or hospitalisation for bleeding was significantly lower in the group invited for screening. Additionally, the number of people who would have to be invited for screening to prevent one event was 91.
Svennberg said, TCTMD notes, “population-based screening for AF provided a net clinical benefit in our elderly population… efforts should be made to increase participation in AF screening. Nonparticipants were at the highest risk of adverse events.”
No country in Europe systematically screens for AF
Investigators of the ongoing AFFECT-EU project, which seeks to identify which patients should be screened for atrial fibrillation (AF) and which screening method is the best approach, report that no country in Europe has a screening programme for AF. Project coordinator Professor Renate Schnabel (University Medical Centre Hamburg-Eppendorf, Hamburg, Germany) comments: “European Society of Cardiology (ESC) guidelines recommend screening for AF, but our interviews revealed that it is not performed systematically in any European country. The healthcare professionals and regulators we spoke to were aware of the consequences of the disease. In their view, opportunistic screening would be the easiest to implement across healthcare systems in the near future, but they agreed that more evidence is needed.”
In its AF White Paper — Put People First, AF Association advocates: “Any contact with a person aged 65 or older is an opportunity to DETECT AF. This can be in the form of a medical contact with a healthcare professional or in a non-healthcare community setting”. For more information, click here
Simple foot test could be used DETECT AF in people with diabetes
Dr Ilias Kanellos (European University of Cyprus, Nicosia, Cyprus) and colleagues found that annual foot assessments for people with diabetes may be a good opportunity to DETECT atrial fibrillation (AF). Two podiatrists, and six podologists, were trained to check for an irregular rhythm while performing pulse palpation of the foot arteries of people with diabetes, and they were also shown how to confirm their findings using a hand-held Doppler ultrasound device.
Of 300 people with diabetes attending an annual foot screening appointment, over a 12-month period, 51 patients (17%) were found to have possible (previously undiagnosed) AF. These patients were then advised to visit a cardiologist for an electrocardiogram (ECG) to reinforce the diagnosis and discuss management.
“In our study, one in six patients with diabetes had previously undiagnosed AF. This presents an opportunity to provide treatment to prevent subsequent [AF-related] strokes,” says Dr Kanellos.
AF is often asymptomatic (without symptoms) and sometimes can only be detected with a pulse rhythm check. Detection is very important because without the right therapies, a person with AF may be five times more likely to have a stroke.
For more information about how to DETECT AF, visit www.KnowYourPulse.org
Protect against serious events
Revised PROTECT against AF-related guidance published
Updated guidance on the safe and effective use of non-vitamin K antagonist oral anticoagulants (NOACs) in people with atrial fibrillation (AF) was both presented at EHRA 2021 and published in EP Europace. A press release reports that the 2021 EHRA Practical Guide on the use of NOACs in patients with AF is now its fourth edition and was produced by EHRA, stating “knowledge on the use of NOACs has greatly advanced – but at the same time new frontiers and challenges have emerged”.
Lead author Professor Jan Steffel (University Heart Centre, Zurich, Switzerland) comments: “The NOAC practical guide complements the ESC AF guidelines by giving specific advice on how to handle these medications in numerous situations encountered in clinical practice. This includes scenarios with limited data on the use of any anticoagulant drug — for example in severe renal insufficiency.”
New project to explore using AI to better select people for ICDs
As outlined at EHRA, a new project is to review using personalised treatment and artificial intelligence (AI) to better select people for an implantable cardioverter defibrillator (ICD). According to a press release, the project aims to personalise prevention of sudden cardiac death after a heart attack (myocardial infarction) by developing a prediction model. Data from several hundred thousand myocardial infarction patients across Europe, the USA and Israel are being analysed using traditional statistical methods and AI to create a clinical prediction model for the individual risk of sudden cardiac death.
A defibrillator implantation strategy based on the predicted individual risk for sudden cardiac death will then be tested in two clinical trials, including more than 3,900 patients in total.
Principal investigator Dr Nikolaos Dagres notes: “The current method of selecting patients for a defibrillator has substantial limitations. In absolute numbers, most sudden cardiac deaths occur in patients with moderately reduced or preserved ejection fraction (above 35%) yet they are left unprotected because they do not qualify for defibrillator implantation according to current guidelines. In addition, as a result of better medical and interventional treatment of myocardial infarction, only a minority of patients who currently qualify for an ICD will ever require it yet may experience unintended shocks or complications associated with the device. Taken together, we clearly need to better select the patients who would benefit from this life-saving therapy… The goal [of the new project] is to reshape the decision making of defibrillator therapy so that those who need it get it, but those who do not need it do not.”
Cannabis users with an arrhythmia more likely to die in hospital
In a study, presented at EHRA 2021, Dr Sittinun Thangjui (Bassett Healthcare Network, Cooperstown, USA) and colleagues found that a cannabis user was more than four times likely to die in hospital if they had an arrhythmia compared with a cannabis user without an arrhythmia. Dr Thangjui observes: “Our study highlights that heart rhythm disorders may be a warning sign for an increased risk of death in people who use cannabis. More studies are needed to confirm our results. In the meantime, it seems sensible to screen these patients for arrhythmias if they present to hospital so that those with a heart rhythm problem can be closely monitored.”
Perfect the patient care pathway
More than 10% of people develop anxiety or depression after having an ICD fitted
According to Professor Susanne Pedersen (Odense University Hospital, Denmark) and colleagues, people who have an implantable cardioverter defibrillator (ICD) should be regularly screened for anxiety and depression. They found that of 1,040 people with an ICD, who answered questionnaires on anxiety, depression, and physical quality of life, 14.5% developed new-onset anxiety and 11.3% developed new-onset depression over a 24-month follow-up period.
Professor Pedersen comments: “Most patients adapt well to living with an ICD. For others it completely changes their life, with worries about shocks from the device, body image, and livelihood as some need to change their job… Our results suggest that more regular screening for depression and anxiety could identify patients who might benefit from additional support
For more information about living with an ICD, download our “Devices for an arrhythmia” booklet.
New consensus document on quality indicators for managing AF
A press release reports that a new document — the first of its kind — outlines internationally agreed quality indicators for the management and outcomes of adults with atrial fibrillation (AF). The document, which was presented at EHRA and published in EP Europace, identifies six domains of care: patient assessment at baseline and follow-up; anticoagulation therapy; rate control strategy; rhythm control strategy; risk factor management; and outcomes. According to the press release, quality indicators were chosen for each domain. For example, a quality indicator in the patient assessment domain was the proportion of patients assessed for stroke risk. In the anticoagulation domain, one quality indicator was the proportion of patients appropriately prescribed this stroke prevention therapy. For risk factor management, the indicator was the proportion of patients with these factors identified (e.g., obesity, smoking, high blood pressure, obstructive sleep apnoea, alcohol excess, lack of exercise, and poor glycaemic control).
Lead author Dr Elena Arbelo (University of Barcelona, Barcelona, Spain) said: “We hope the quality indicators will help institutions to assess and monitor adherence to clinical practice guidelines. Ultimately this should lead to improved quality of care for patients with AF.”
New project seeks to improve management of elderly people with AF
The European Society of Cardiology (ESC) has launched “EHRA-PATHS”, which a press release describes an EU-funded project to improve the management of elderly people who have atrial fibrillation (AF) alongside other health conditions. The press release states that EHRA-PATHS is the “first multicentre EU-wide project on integrated care for elderly patients with AF and at least one additional chronic condition. EHRA is coordinating the programme, also a first, which involves cardiology and other specialties such as endocrinology and nephrology in each hospital, another novelty”.
The first phase of the project involves mapping multimorbidity and polypharmacy in elderly patients with AF across Europe, including an analysis of potential differences between women and men. The second phase is to discover whether co-existing conditions are currently handled in clinical practice and identify gaps in management. In the third phase, a new overall care pathway will be developed as a software tool.
Scientific coordinator Professor Hein Heidbuchel, EHRA’s Immediate Past-President, said: “As a result of this project, we hope the presentation of AF will be taken as an opportunity by the medical community to methodically address comorbidities. This should lead to better management of individual patients, less polypharmacy, and improved adherence to effective therapies.”