Opportunistic Screening for Atrial Fibrillation in a Podiatry Clinic
Caroline McIntosh, PhD, Professor of Podiatric Medicine at University of Galway in Ireland presented findings of her research on the benefit of screening for atrial fibrillation in a podiatry clinic setting.
Atrial fibrillation (AF) is the most common progressive tachyarrhythmia worldwide leading to an increased risk of stroke, systemic embolism, and cardiovascular morbidity and mortality.1,2 AF can also lead to a significant public health burden on resources. She shares that it the condition often remains undiagnosed and untreated, possibly leading to devastating outcomes.
AF is an abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart. Dr. McIntosh shares that it often begins as short periods of abnormal beating, which can become longer over time.
Classification of atrial fibrillation (in Europe) includes categories of first diagnosis, paroxysmal, persistent, long-standing persistent, and permanent.3 Clinically, patient presentation varies in severity and type, with many being asymptomatic. Dr. McIntosh goes on to say that when present, symptoms often relate to the tachycardia, and can include palpitation, dizziness and chest pain. Prevalence of AF increases with age (4.2% between 60-69 years), and estimates convey that 6-12 million people in the United States will be impacted by the year 2050, and 17.9 million in Europe by 2060.4-6
Modifiable risk factors for AF include congestive heart failure, valvular heart disease, diabetes, hypertension, smoking, obesity, and excess alcohol intake. Nonmodifiable risk factors include genetics, gender, and age.7 Atrial fibrillation has a 5-year mortality rate of 48.8 percent.8
Benefits of screening may be realized particularly as AF can be silent or subclinical, says Dr. McIntosh. Early identification may then allow for early antithrombotic treatment, thus reducing stroke and premature death.1,5,6 Screening can be opportunistic (using a health care practitioner during a routine consultation) or systematic (all above a certain criteria are invited to attend a screening). She adds that screening tools could include palpation of pulses, 12-lead ECG with expert interpretation. Portable smart phone ECG and photoplethysmography are also emerging.
Dr. McIntosh then shared the current research on screening for atrial fibrillation in podiatry clinics, including each of several phases. Some are currently published,9,10 and the latest phase is in preparation for submission for publication.
In the ALERT study, phase 1 was a scoping review.10 A 12-lead ECG, smartphone-based Alivecor, and pulse palpation, all took place with patients in community or urban/rural primary care settings. In phase 2, a cross-sectional study, 214 adults greater than 18 years of age, who were attending community podiatry, and able to give informated consent were studied. They underwent vascular assessment, including pulses, doppler, ABPI, TBPI, the MoCA test. If the team detected an arrythmia they conducted CHADSVAS scoring and ECG with possible referral to cardiology. If no arrhythmia was detected, the patient returned to standard podiatry care.
MoCA, says Dr. McIntosh, is the Montreal Cognitive Assessment Tool, a validated option for health care practitioners to detect and evaluate mild cognitive impairment. Normal scores are 26 to 30. CHADSVAS scores, she says, rate risk factors for stroke.
As far as the data they collected, they found arrhythmias in 33 patients out of the 214, more as age increased. There was a statistically significant difference, she says, between MoCA scores for those with arrhythmia and those without.
Phase 3 is a scoping review of 40 studies that Dr. McIntosh says the team is ready to submit for possible publication. The mean prevalence she says they found in the studies of mild cognitive impairment in patients with atrial fibrillation was 37.84%, with primary proposed pathology mechanisms of white matter lesions, cardiovascular risk, silent cerebral infarct, and cerebral hypoperfusion.
She states that there are limitations to her team’s research, including limited external validity, small sample size, a homogenous population, data collection during COVID-19, and that the podiatry population in that area consists of high-risk individuals with multiple comorbidities placing the limb at risk. However, she points out that the strengths include the distinct possibility of positive impact for the patients.
Dr. McIntosh concludes that the prevalence of previously undiagnosed AF in podiatric patients may be higher, particularly in high-risk, older populations. She recommends targeting those at greatest risk, including those over 65. Emerging novel technology, she says, may increase accessibility to such screening. And doppler, she adds, seems to be a viable tool with which podiatrists can play a role in screening. Overall, she feels that more research is needed on this topic.
Dr. McIntosh discloses a grant from Bayer, Ltd. for the research discussed.
References
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2. Wetterslev M, Haase N, Hassager C, et al. New-onset atrial fibrillation in adult critically ill patients: a scoping review. Intensive Care Med. 2019;45(7):928-938.
3. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothoracic Surg. 2016;50(5):e1-e88.
4. Benito L, Coll-Vinent B, Gomez E, et al. EARLY: a pilot study on early diagnosis of atrial fibrillation in a primary healthcare centre. EP Europace. 2015;17(11):1688-1693.
5. Morillo CA, Banerjee A, Perel P, Wood D, Jouven X. Atrial fibrillation: the current epidemic. J Geriatr Cardiol. 2017;14(3):195-203.
6. Berge T, Brynildsen J, Netmangen Larssen HK, et al. Systematic screening for atrial fibrillation in a 65-year-old population with risk factors for stroke: data from the Akershus Cardiac Examination 1950 study. Europace. 2018;20(FI_3):f299-f305.
7. Lau DH, Nattel S, Kalman JM, Sanders P. Modifiable risk factors and atrial fibrillation. Circulation. 2017;136(6):583-596.
8. Piccini JP, Hammill BG, Sinner MF, et al. Clinical course of atrial fibrillation in older adults: the importance of cardiovascular events beyond stroke. Eur Heart J. 2014;35(4):250-256.
9. Stang D, Hicks L, Fox M, et al. Opportunistic podiatry-led detection of heart arrhythmias (atrial fibrillation): a step towards standard care. The Diabetic Foot Journal. Available at: https://diabetesonthenet.com/diabetic-foot-journal/opportunistic-podiatry-led-detection-of-heart-arrhythmias-atrial-fibrillation-a-step-towards-standard-care/ . Published August 4, 2022. Accessed January 20, 2022.
10. Candy E, MacGilchrist C, Tawfick W, McIntosh C. Screening for atrial fibrillation in community and primary care settings: a scoping review. J Atr Fibrillation. 2021;13(5):2452.
