Stroke is a major public health issue nationally and internationally and remains one of the leading causes of morbidity and mortality globally (1). It is the leading cause of acquired disability (2) and the third leading cause of death in Ireland (3). Atrial fibrillation (AF), the most common cardiac arrhythmia, is a major risk factor for stroke (4), increasing the risk of stroke five-fold (5). AF causes the heart to beat irregularly which can result in the formation of blood clots, the blood clots can migrate to the brain and cause a stroke (4). AF affects approximately 11% of the population over 65 years old in Ireland (6) and its incidence increases significantly with age. It is a condition that is often asymptomatic making it difficult to diagnose (5). It is often identified when an individual presents with a devastating stroke (7). If identified AF can be effectively treated with oral anti-coagulation therapy reducing the risk of stroke by up to two thirds (8).
AF has been identified as a condition that could be effectively screened for (9). It is an important health issue, a suitable test for AF exists, acceptable treatment and facilities to provide treatment are available (10). The optimal mode for AF screening has, as yet, not been identified and controversy around identifying this continues (11). Experts in the area have suggested that the screening should be both country and health service specific (9). There are various modes in which to identify AF including pulse palpation, mobile ECG devices, personal health monitoring devices and the current ‘gold standard’ a 12 lead ECG. Dr Diarmuid Quinlan a general practitioner (GP) in Cork developed and implemented a GP led, patient-centred initiative to improve patient literacy regarding stroke, to increase diagnosis of AF and to optimise oral anti-coagulation in patients with AF. The initiative entitled ‘the ABCD of AF stroke prevention’ harnesses existing GP skills and resources to facilitate the implementation in practice.
The initiative involves Awareness, Baseline ECG, Creating an AF register and using a Decision support tool. Awareness aims to improve patient health literacy on stroke through a brief education provided to patients by the GP based on Irish Heart Foundation act-FAST campaign. The Irish Heart Foundation act-FAST campaign was designed to help individuals recall the main warning signs of a stroke; has their Face fallen to one side, can they raise both Arms over their head and keep them there, is their Speech slurred and Time to call emergency services should they observe any one of these symptoms. Baseline ECG involves conducting an ECG using a mobile device, My Diagnostick, to screen asymptomatic patients for AF. The device is a validated highly sensitive and specific screening tool (12). Creating an AF register involves placing all patients with a diagnosis of AF at the practice and newly identified cases of AF on the AF register. Decision support tool involves optimising oral anticoagulation in patients with a diagnosis of AF using the Keele University oral anti-coagulation Decision support tool. This tool was developed at Keele University in conjunction with the National Institute for Health and Care Excellence (NICE) to enable early optimal oral anti-coagulation initiation by the GP. The support tool was developed using the NICE guidelines and has been validated for use (13).
The ABCD of AF stroke prevention initiative was a success within Dr Quinlan’s practice for which he received two awards; (i)The Irish College of General Practitioners (ICGP) awarded Dr Quinlan the National Quality & Safety in Practice award in 2018 and (ii) the GP Buddy Safety in Practice award also in 2018. Patient awareness of the signs of stroke increased. Twelve new cases of AF were identified. The AF register at the practice grew from 7.8% of adults at the practice in September 2014 to 9.1% in September 2017. Patient details were inputted into the Keele Decision Support Tool to support optimal oral anti-coagulation therapy in 62 patients with known AF. This initiative is being used to inform a pilot screening programme for AF in the Cork area. The initiative launched in Cork in January 2020 will evaluate the feasibility and acceptability of screening for AF in primary care using a mobile ECG device from the perspectives of the healthcare professionals who provide the screening and the patients who receive it. The pilot will draw on some of the key elements of the ABCD of AF stroke prevention including conducting a baseline ECG and using the Keele University oral anti-coagulation decision support tool.
Further information relating to the study can be obtained by emailing Aileen Callanan aileen.callanan@ucc.ie, PhD Researcher, School of Public Health, University College Cork
The Safety in Practice award was sponsored by Medisec was presented to Dr Diarmuid Quinlan (2nd right) for The ABCD of AF-Stroke Prevention in GP, by Joe Newell, CEO of gpbuddy and in-house counsels at Medisec, Aisling Malone and Niall Rooney.
A selection of photographs from the study launch evening on 28th January 2020 at St Mary’s Primary Care Centre, St Mary’s Health Campus, Gurranabraher, Cork.
References
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13. Keele University and the National Institute for Health and Care Excellence (NICE), Prescribing Decision Support Ltd at the Centre for Medicines Optimisation, Boehringer Ingelheim Ltd. Decision Support, Anticoagulation therapy for the prevention of stroke and systemic embolism in atrial fibrillation. United Kingdom: Keele University; 2017 [Available from: https://www.anticoagulation-dst.co.uk/.