Atrial Fibrillation: Maintaining momentum

Atrial fibrillation (AF), one of the most common types of irregular heart rhythm and a condition which is estimated to affect over 100,000 people in Scotland, is a major cause of Scotland’s third biggest killer: stroke.

In fact, AF increases your likelihood of having a stroke by five times.

People over 40 have at least a one in four risk of developing AF, and in Scotland the rates are likely to increase due to an ageing population.

In 2016, 96,346 had been diagnosed with the condition but it is estimated that a further 50,000 live with it undiagnosed.

An inquiry was launched by the Cross-Party Group on Heart Disease and Stroke in the Scottish Parliament. This culminated in a report, ‘A Focus on Atrial Fibrillation in Scotland’, which was published last week and lays out 10 recommendations for the Scottish Government.

These cover diagnosis, treatment, the use of data and the involvement and informing of patients, but with a third of people with AF unaware that they have it, how realistic are these recommendations, and what further challenges lie ahead?

Holyrood brought together the major contributors to the report, including physicians, patients, MSPs and charities; the British Heart Foundation (BHF) Scotland, Stroke Association and Chest, Heart & Stroke Scotland, in a roundtable event to discuss these issues and more. 

“We don’t want just a talking shop, we want action,” said Dr Terry Quinn, a senior clinical lecturer at the University of Glasgow, pointing to the fact the group had already broken down silos in working together to produce the report.

Colin Smyth MSP, co-convener of the cross-party group, said the report’s recommendations “wrote themselves because the evidence was so clear from people”.

The inquiry consulted both clinicians and people living with AF. As well as a wider survey, four roundtable meetings were held in the Scottish Parliament throughout October and November 2017.

The BHF’s Kylie Barclay said awareness of the condition had been raised at the last of these, which focused on patient experience.

“They certainly said awareness of the condition was important. For them, but also for their families as well, to understand what they might experience.”

But awareness of the condition also needs to be raised among clinicians, it was agreed, if detection and diagnosis rates are to improve and optimal treatment provided.

Sarah Smith, cardiac coordinator with Chest, Heart & Stroke Scotland has a background as a practice nurse.

“From my personal experience in clinical practice, it would be related to opportunistic case finding and making sure you incorporate that into regular practice, as good clinical practice, when you’re maybe reviewing a patient who has come in for their diabetes review or for something else, whether they are reporting symptoms or not,” she said.

Cardiologist Dr David Murdoch agreed. “Most of the folk we’re talking about screening are being seen already. As Sarah says, they’re diabetic, they’re hypertensive. They’re seen by pharmacists, podiatrists, GPs. They’re in hospital. They’re there, we’re just not picking up the AF.”

“We need to identify,” said Professor Lis Neubeck of Napier University. “We’ve got a population we know are at high risk of having atrial fibrillation, it’s fairly easy to identify those people we should be targeting.” AF can be picked up by a simple check of someone’s pulse. Diagnosis must then be confirmed by a 12 lead electrocardiogram (ECG) test.

Pulse checks can be inaccurate but there are a number of new technologies which are more accurate at detecting AF. The report highlights the potential for technology to play a role in improving AF detection and diagnosis and recommends investment in proven technologies to detect AF.

Colin Oliver of the Stroke Association said the charity had a pilot project trialling single lead ECG tests in the workplace and other community settings. 

The report recommends targeted AF case finding programmes for those most at risk (age over 65 years, those with previous stroke and those with existing cardiovascular risk factors). 
It also raises the shortage of cardiac physiologists working within Scotland.

The pathway for AF patients after diagnosis is not consistent across Scotland. Some boards have dedicated AF clinics and the BHF’s Morven Dunn said this provided very high levels of patient satisfaction and helped to ensure prompt, appropriate treatment.

Murdoch said healthcare professionals could be equipped to make more informed decisions around prescribing anticoagulants, medicines that help prevent blood clots.
“We have better treatments now, or treatments that are more palatable to patients,” said Quinn. 

The introduction of newer anticoagulants (DOACs) has created space for more choice about which medication best suits each patient’s needs but these medications are currently more expensive than the most commonly prescribed anticoagulant, Warfarin.

“When you talk about the economics of these things, you have to remember how expensive a stroke is,” said Quinn. “Atrial fibrillation causes the most disabling strokes, so that’s then someone spending two or three years in a care home. So you have indirect costs saved. The problem is the savings aren’t necessarily within the budget in that location, but from a societal perspective there is a cost saving, and that’s been demonstrated.”

So why are some people diagnosed with AF not receiving appropriate, timely treatment? “Within four weeks of diagnosis you’re at most risk (of an AF-related stroke),” said Neubeck. “So if we pick them up we have to have this joined up so they get onto the right treatment. From my point of view, that’s probably about electronic decision support or something, that helps those people make those choices in primary care.”

Most people, she added, choose treatment if they are presented with clear risk calculations of their likelihood of stroke. “About 50 per cent of people with AF don’t know that they are at risk of stroke,” she said. “Knowledge is poor.”

“I think we’re not very good as health professionals at explaining risk to patients,” said Murdoch. 

“But on the NICE website with regard to AF there is a very good patient information section.”

Dr Anna Maria Choy of the University of Dundee added: “Regardless of whether they’re seen by specialists or primary care, I think the parallel stream of work that needs to be done is patient education and support.”

AF patient Paul Hodson, said resources would still present a challenge, especially when people like him had a number of conditions to deal with at once. He had a stroke while waiting in hospital for a heart operation. 

“I’m OK with the atrial fibrillation because I understand it,” he said. “It’s the other things. Because I have a balance in my body, not just atrial fibrillation.”

He cited regular contact with clinicians as an important factor in feeling informed and in control of his recovery.

It was agreed that a clear and consistent clinical pathway for people diagnosed with AF would encourage better coordination between primary and secondary care.

“We have laid down a pathway which says ECG within seven days, and then anticoagulation within two weeks. But even getting an ECG in seven days is difficult in some boards,” said Murdoch.
Although health boards will always need to tailor approaches to local needs, strong central guidance should ensure variation is kept to a minimum, said Dunn.

“It is not rocket science,” said Choy of the University of Dundee. “An ECG is a basic thing in this day and age. Seven days to get an ECG is almost unacceptable.”

While there was a feeling most clinicians were supportive of the proposals and that boards would be responsive to new guidelines, there was recognition that effective use of data could be one of the biggest challenges.

Quinn said Scotland had been good at providing a national audit of the numbers of people who have had a stroke, but it served to show how many people with AF were being missed. “So we do have data about how badly we’re doing at the thing we want to prevent.”

The integration of primary and secondary care data remains a challenge.

Murdoch said he had been working with the BHF on using Scotland’s existing SPIRE software to collect data from primary care records. The Information Services Division (ISD), he suggested, could provide linkage to long-term outcomes data.

Boards, however, are not required to provide outcomes data and have shown little interest in it, he added.

“When we’re talking about measuring outcomes, we need the data,” said Neubeck. “If we can’t get access to it, we can’t tell if anything we do has made a measurable impact. I don’t think it is unique to this condition.”

Dunn said: “It works back to front. It starts with the data, then you have to have robust systems for diagnosis and treatment.”

For health boards, she added: “We don’t need to be prescriptive about how health boards tackle [both AF and data collection] but we need to be prescriptive about what the outcome is.”

Smith said there was increasing recognition that lifestyle factors are associated with AF, and that losing weight can lead to a reduction of symptoms and frequency of atrial fibrillation. 

There was a recognition that the solutions to the challenges presented by AF and other long-term conditions will reach beyond the scope of healthcare systems alone to wider agendas, policies and programmes.

Smyth said although he didn’t envisage much of a political barrier to the recommendations in the report, the lifestyle risk factors would be the bigger challenge.

“One of the things that strikes me when you read the report and listen to the evidence is the risk factors again come back to alcohol consumption, smoking, obesity,” he said, predicting the new obesity strategy could have an impact.

He suggested a separate prevention fund was needed because transferring funds from acute services wasn’t realistic. 

“Unless you front load it, you’re not going to get the return,” he said.

Neubeck agreed. “The commonalities are increasingly obvious. Public health investment is a priority,” she said. “Sugary drinks, increasing availability of cycle paths, safe walking, all of these things that will support prevention of a number of chronic conditions.”

However, Murdoch pointed to the Keep Well programme, which struggled to show meaningful benefit despite costing “millions of pounds”.

“There’s no doubt the smoking ban made a huge difference,” he said. “In my career that’s the thing that’s made the biggest difference to heart disease. Minimum unit pricing for alcohol could make a huge difference. It’s the draconian legislation that does it.”

High hopes, then, for the Scottish Government’s obesity strategy.

In terms of the recommendations of ‘A Focus on Atrial Fibrillation in Scotland’ there was cautious optimism in the room.

“It’s one thing writing it all down, saying we should do this and do that. Actually making it happen on the ground is a different story,” said Murdoch.

There was an agreement that the group should build in a review in a year’s time to mark progress.

“We have, by luck I think, done this at a very opportunistic moment,” said Dunn. “We have great enthusiasm from clinicians. Clinicians are desperate to do things better, desperate to make the changes. 

“Patients living with atrial fibrillation wanted things to be better, and having the three big charities working together to push this forward, and through parliament, is a really positive step. 

“Together we could make a huge difference.”

Quinn agreed. “We have broken the silos ourselves,” he said. “As a collegiate body, we’re ready to work with government.”