Introduction
Atrial fibrillation (AF) is a spectrum of disease and affects around 5.5% of adults aged 55 years and over.1 It can be either paroxysmal, persistent or permanent, and although some patients may be asymptomatic, it is often associated with symptoms such as palpitations, breathlessness, fatigue and reduced exercise capacity. Patients with symptomatic AF are treated with either a rate or rhythm control strategy. Rate control is often the first-line approach for AF with an onset of greater than 48 hours, and can be achieved with acute and then long-term use of beta-blockers, calcium channel blockers, cardiac glycosides or combination therapy. Beta-blockers are considered first-line long-term therapy for patients with persistent or permanent AF and symptoms related to rapid ventricular rate (fast AF) for symptomatic relief. Community follow-up monitoring is necessary to guide effective treatment. Conventionally, 12-lead ECGs have been used, but the advent of reliable single-lead ECGs with accurate built-in AF detection algorithms have the potential to streamline this monitoring process.
Single-lead ECGs could also have a role in community detection of AF. A diagnosis of AF can be difficult to make in the community as up to 62% is paroxysmal and up to 40% is asymptomatic.2 3 In the UK, AF is detected through opportunistic investigation as systematic screening is currently not recommended by the UK National Screening Committee predominantly due to a lack of outcome evidence.4 Detection is important because new-onset AF is thought to account for one-fifth of patients hospitalised for ischaemic stroke.5 Indeed, AF is a well-established independent risk factor of ischaemic stroke,6 with convincing evidence for direct causality.5 Having controlled for confounding, device-detected AF lasting at least 1 hour in 3 months (0.046% of the time) is associated with a 2.11-fold increase in stroke risk compared with no AF.7 Anticoagulation in the form of direct oral anticoagulants or adjusted-dose warfarin reduces stroke risk by over 60%.8 NICE recommends anticoagulation in moderate- to high-risk patients.9
Previously, when ECG investigation had been required, our Acute Community Team in the Neath Port Talbot area have had to rely on undertaking a 12-lead ECG in the community. This can be a cumbersome and lengthy process that risks inappropriate tachyarrhythmia management, missed or delayed diagnosis of paroxysmal AF with adverse implications for initiation of appropriate anticoagulation. There is mounting evidence for the utility of integrating single-lead ECGs into healthcare provision in a number of settings.10–16 This pilot initiative aimed to test the feasibility of integrating a single-lead hand-held ECG system, the AliveCor, into community monitoring of treatment in patients with recently diagnosed fast AF and opportunistic community diagnosis of AF.