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Screening for AF in Elders: Keep Your Finger on the Pulse!
Pulse-taking followed by electrocardiography in patients with an irregular pulse is the best screening approach.
Atrial fibrillation (AF) occurs in about 5% of people older than 65. Detection and treatment with warfarin can lead to relative risk reductions of 68% for ischemic stroke and 25% for mortality. As part of the Screening for Atrial Fibrillation in the Elderly (SAFE) study, researchers analyzed data for 14,802 patients (65 or older) in 25 intervention and 25 control practices during a 12-month period. Patients in intervention practices were randomized to either systematic AF screening by electrocardiography or opportunistic screening in which ECGs were performed only if the pulse was irregular on physical examination.
New-onset AF was detected in 1.63% of patients in intervention practices versus 1.04% of those in control practices. Detection rates were similar in the systematic and opportunistic screening groups (1.62% and 1.64%, respectively). Overall, 34% of patients in the opportunistic group who had an irregular pulse declined ECGs, and only 53% of patients in the systematic screening group underwent ECGs. The authors conclude that opportunistic screening, with pulse-taking followed by electrocardiography in patients with irregular pulse, is the preferred screening method for AF in older patients.
Comment: Vital signs are vital, but simply looking at the triage nurse’s recorded heart rate doesn’t tell the whole story. In this study, screening — using just a simple pulse check — identified almost twice as many patients with AF as did routine practice. The bottom line: Feel the quality of the pulse on every patient older than 65, especially those who are not likely to have an ECG (e.g., those with lacerations). If you suspect new-onset AF, order an ECG, and arrange prompt follow-up — you might prevent a future stroke in a patient who presented with an unrelated complaint. With the ever-increasing challenges in access to care, the emergency department offers an opportunity for clinicians to significantly decrease future morbidity and mortality by detecting critical abnormalities in patients who might be unaware of them. Preventing a stroke is much more effective than treating one!
Published in Journal Watch Emergency Medicine August 30, 2007
Citation(s):
Fitzmaurice DA et al. Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: Cluster randomised controlled trial. BMJ 2007 Aug 25; 335:383. (http://dx.doi.org/10.1136/bmj.39280.660567.55)
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