Implementation of a screening and management pathway for chronic obstructive pulmonary disease in patients with atrial fibrillation
Authors: Van Der Velden R , Hereijgers M , Franssen F , Verhaert D , Habibi Z , Gawalko M , Hermans A , Betz K , Schotten U , Vernooy K , Hendriks J , Heidbuchel H , Desteghe L , Simons S , Linz D 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Introduction
Chronic obstructive pulmonary disease (COPD) is a well-recognized risk factor for atrial fibrillation (AF) and negatively impacts symptom burden and AF rhythm control treatment. Nevertheless, there are currently no guideline recommendations or practical guides about whether or not and how to screen for COPD.

Purpose
To describe the implementation of an integrated screening and management pathway for COPD in patients with diagnosed AF, into the existing pre-ablation work-up embedded in an AF outpatient clinic infrastructure.

Methods
Unselected consecutive AF patients scheduled for catheter ablation were prospectively screened for airflow limitation using handheld (micro)spirometry devices. Patients with a forced expiratory volume (FEV) in one second (FEV1)/FEV in six seconds ratio of ≤0.73 or a FEV1/forced vital capacity ratio of &lt;0.70, depending on the device, were offered referral to a pulmonologist. The COPD assessment test (CAT) (eight items scoring symptoms such as dyspnoea and coughing on a scale of 0-5) was applied to evaluate perceived disease burden, whereas the Respiratory Health Screening Questionnaire (RHSQ) (ten items scoring age, smoking, body mass index and respiratory symptoms) was evaluated as an additional screening tool. The COPD screening and management pathway consisted of six steps: 1) patient education about COPD, 2) handheld (micro)spirometry under supervision of a specialized AF nurse, 3) review of diagnostic results, 4) telephone consultation with the patient in case of results suggestive of airflow limitation, 5) referral if opted by patient and 6) full pulmonary function testing and consultation with a pulmonologist (Figure 1).

Results
In total, 232 patients (median age 66 [59-71], 31.9% female, 33.6% self-reported dyspnoea) were included in this screening and management pathway. Screening (micro)spirometry yielded interpretable results in 88.8% of patients. Airflow limitation was observed in 47 patients (20.3%) of whom 29 (12.5%) opted for referral to the pulmonologist and 17 (7.3%) received a final diagnosis of chronic respiratory disease, either COPD or asthma (11 newly diagnosed). The majority of these 17 patients (70.6%) scored high on the CAT (score ≥10), whereas 14 (82.4%) had a moderate-to-highly increased risk of COPD based on the RHSQ (score ≥16.5).

Conclusions
A COPD care pathway can successfully be embedded in an existing AF patient clinic infrastructure, using (micro)spirometry and remote analysis of results. Although all patients chose to perform handheld (micro)spirometry, only 60% of those in whom referral was advised opted for referral. Preselection of patients based on respiratory symptoms as well as increasing patient involvement might increase patient acceptance for respiratory analysis, and requires further research.