Implementing an end-to-end pathway for detection, diagnosis, and management of atrial fibrillation in the risk-stratified patients: results from the atrial fibrillation stroke prevention hub program
Authors: Read W , Kuriakose S , Baldwin A , Sinha D , Sohaib A , Evens S , Kidd J 
Published: November 2023

Abstract

Background
Atrial fibrillation (AF) is a prevalent cardiac arrhythmia linked with a five-fold increased risk of ischemic stroke. Despite the need for pulse rhythm checks of reasonable duration in selectively identified high-risk patients, the NHS is under pressure to perform these tasks during daily practice in primary care to prevent stroke.

Purpose
This program aimed to establish an end-to-end pathway to identify, detect, diagnose, and manage high-risk patients with no prior AF diagnosis.

Methods
The AF Stroke Prevention Hub program was aimed at patients aged 65 and above with a history of heart failure or stroke/transient ischemic attack. Data from electronic patient records identified these patients, while exclusion criteria consisted of known AF, implanted cardiac devices, end-stage renal disease and end-of-life care. The program used a medically certified smartphone application to monitor heart rate and rhythm and track symptoms using photoplethysmography (PPG). Patients were facilitated to perform a minimum of two measurements per day, for seven days. Those who were digitally excluded were offered an assessment in a face-to-face clinic appointment. Based on the PPG recordings, patients with a positive finding received a confirmatory ECG examination and anticoagulation therapy, once the diagnosis was established, within 48 hours.

Results
Between February 2022 and February 2023, after applying inclusion and exclusion criteria, six hundred and sixty-nine patients were found to be eligible from 4 primary care practices. Two hundred and sixty-seven patients were issued PPG applications after obtaining consent. In total, two hundred and ten patients completed the PPG-based, 7-day monitoring period. The technology adoption rate was 78.65% in this group of patients.
Among the high-risk group of cardiac failure, four patients were detected with possible AF based on the PPG recordings. All four were confirmed via a 12-lead ECG or a Holter monitor, with an AF detection rate of 9.09%. Combining all stratified risk patient cohorts, ten (4.76%) were detected with possible AF based on the PPG recordings and six (2.8%) were verified based on a confirmatory 12-lead ECG or a 7-day Holter. All patients with newly diagnosed AF received anticoagulation therapy and were managed accordingly, while the remaining patients received advice regarding self-management, lifestyle, and yearly health checks.

Conclusion
Compared to the current NHS opportunistic pulse check, where the detection rate is &lt;1%, the AF Stroke Prevention Hub program successfully identified patients with a significantly higher detection rate. The hub delivered an end-to-end pathway allowing real-time reporting and triaging of patients, early detection, appropriate confirmation, and rapid treatment with favorable real-life technology adoption. Expanding the data-driven program to a wider difficult-to-reach population could reduce the burden on NHS and improve patient outcomes.