How is atrial fibrillation detected in everyday healthcare? Results of a Dutch cohort study.

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia with serious potential consequences when left untreated. For timely treatment, early detection is imperative. We explored how new AF is detected in patients aged ≥ 65 years in Dutch healthcare. METHODS: The study cohort consisted of 9526 patients from 49 Dutch general practices in the usual-care arm of the Detecting and Diagnosing Atrial Fibrillation study. We automatically extracted data from the electronic medical records and reviewed individual records of patients who developed AF. Patient selection started in 2015, and data collection ended in 2019. RESULTS: We included 258 patients with newly diagnosed AF. In 55.0% of the patients, the irregular heartbeat was first observed in general practice and in 16.3% in the cardiology department. Cardiologists diagnosed most cases (47.3%), followed by general practitioners (GPs; 33.7%). AF detection was triggered by symptoms in 64.7% of the patients and by previous stroke in 3.5%. Overall, patients aged 65-74 years more often presented with symptoms than those aged ≥ 75 years (73.5% vs 60.6%; p = 0.042). In 31.5% of the patients, AF was diagnosed incidentally ('silent AF'). Silent-AF patients were on average 2 years older than symptomatic-AF patients. GPs less often diagnosed silent AF than symptomatic AF (21.0% vs 39.0%; p = 0.008), whereas physicians other than GPs or cardiologists more often diagnosed symptomatic AF than silent AF (34.6% vs 11.9%; p < 0.001). Most diagnoses were based on a 12-lead electrocardiogram (93.8%). CONCLUSION: Diagnosing AF is a multidisciplinary process. The irregular heartbeat was most often detected by the GP, but cardiologists diagnosed most cases. One-third of all newly diagnosed AF was silent.

Correction to: How do Dutch general practitioners detect and diagnose atrial fibrillation? Results of an online case vignette study.

Following publication of the original article [1], the authors opted to remove the authors full name from.

How do Dutch general practitioners detect and diagnose atrial fibrillation? Results of an online case vignette study.

BACKGROUND: Detection and treatment of atrial fibrillation (AF) are important given the serious health consequences. AF may be silent or paroxysmal and remain undetected. It is unclear whether general practitioners (GPs) have appropriate equipment and optimally utilise it to detect AF. This case vignette study aimed to describe current practice and to explore possible improvements to optimise AF detection. METHODS: Between June and July 2017, we performed an online case vignette study among Dutch GPs. We aimed at obtaining at least 75 responses to the questionnaire. We collected demographics and asked GPs' opinion on their knowledge and experience in diagnosing AF. GPs could indicate which diagnostic tools they have for AF. In six case vignettes with varying symptom frequency and physical signs, they could make diagnostic choices. The last questions covered screening and actions after diagnosing AF. We compared the answers to the Dutch guideline for GPs on AF. RESULTS: Seventy-six GPs completed the questionnaire. Seventy-four GPs (97%) thought they have enough knowledge and 72 (95%) enough experience to diagnose AF. Seventy-four GPs (97%) could order or perform ECGs without the interference of a cardiologist. In case of frequent symptoms of AF, 36-40% would choose short-term (i.e. 24-48 h) and 11-19% long-term (i.e. 7 days, 14 days or 1 month) monitoring. In case of non-frequent symptoms, 29-31% would choose short-term and 21-30% long-term monitoring. If opportunistic screening in primary care proves to be effective, 83% (58/70) will support it. CONCLUSIONS: Responding GPs report to have adequate equipment, knowledge, and experience to detect and diagnose AF. Almost all participants can order ECGs. Reported monitoring duration was shorter than recommended by the guideline. AF detection could improve by increasing the monitoring duration.

Current practice of Dutch cardiologists in detecting and diagnosing atrial fibrillation: results of an online case vignette study.

INTRODUCTION: Detection of atrial fibrillation (AF) is important given the risk of complications, such as stroke and heart failure, and the need for preventive measures. Detection is complicated because AF can be silent or paroxysmal. Describing current practice may give clues to improve AF detection. The aim of this study was to describe how cardiologists currently detect AF. METHODS: Between December 2014 and May 2015, we sent Dutch cardiologists an online questionnaire. Firstly, we asked which tools for detection of AF their department has. Secondly, we presented six case vignettes related to AF, in which they could choose a diagnostic tool. Thirdly, we compared the results with current guidelines. RESULTS: We approached 90 cardiology departments and 48 (53%) completed the questionnaire. In asymptomatic patients with risk factors according to CHA2DS2-VASc, 40% of the cardiologists would screen for AF. In patients with signs or symptoms of AF, all but one cardiologist would start a diagnostic process. In both vignettes describing patients with non-frequent symptoms, 46% and 54% of the responders would use short-term (i. e. 24- or 48-hour) electrocardiographic monitoring, 48% and 27% would use long-term (i. e. 7 day, 14 day or one month) monitoring. In both cases describing patients with frequent symptoms, 85% of the responders would use short-term and 15% and 4% long-term monitoring. CONCLUSION: Dutch cardiologists have access to a wide variety of ambulatory arrhythmia monitoring tools. Nearly half of the cardiologists would perform opportunistic screening. In cases with non-frequent symptoms, monitoring duration was shorter than recommended by NICE.

Benefits of an open access echocardiography service: a Dutch prospective cohort study.

BACKGROUND: Open access echocardiography has been evaluated in the United Kingdom, but hardly in the Netherlands. The echocardiography service of the SHL-Groep in Etten-Leur was set up independently from the regional hospitals. Cardiologists not involved in the direct care of the participating patients evaluated the echocardiograms taken by ultrasound technicians. AIMS: We estimated the reduction in the number of referrals to regional cardiologists, the adherence of the general practitioners (GPs) to the advice of the evaluating cardiologist, GPs' opinion on the benefit of the echocardiography service and GPs' adherence to the diagnostic protocol advocated in the Dutch clinical guideline for heart failure. METHODS: A prospective cohort study was performed. Patients were included from April 2011 to April 2012 (N = 155). Data from application forms (N = 155), echocardiography results (N = 155) and telephone interviews with GPs (N = 138) were analysed. RESULTS: GPs referred less patients to the cardiologist than they would have done without echocardiography available (92 % vs. 34 %, p < 0.001). They treated more patients by themselves (62 % vs. 10 %, p < 0.001). Most GPs (81 %) followed the advice presented on the echocardiogram result. Most GPs (82 %) found the service had clinical benefit for the patient. Sixty two percent of echocardiography requests met the criteria of the Dutch clinical guideline for heart failure. CONCLUSION: Open access echocardiography saved referrals to the cardiology department, saved time, and enabled GPs to treat more patients by themselves. Adherence to diagnostic guidelines for heart failure was suboptimal.