Pulse checks 'could prevent 12,000 strokes'

The Daily Mail reports that, if doctors checked the pulse of every patient they see, this measure could “prevent 12,000 strokes a year”.

The aim of the pulse checks would be to pick up cases of atrial fibrillation, a common heart rhythm disorder that increases the risk of a stroke.

The figure comes from a report released by the Atrial Fibrillation Association (AFA) and Anticoagulation Europe (ACE), which warn that there is a “silent epidemic” of atrial fibrillation and that this will worsen in the UK as the population ages. The report also sets out a number of ways that might improve the diagnosis and treatment of atrial fibrillation, including campaigns to raise awareness, further training for GPs and improved access to heart monitoring when a case is suspected.

What is atrial fibrillation?

Atrial fibrillation is a heart rhythm disorder where the upper chambers of the heart (the atria) contract in a faster and shallower way than normal, causing an irregular heartbeat. While this is happening the heart is less effective at pumping blood around the body.

There are three different forms of atrial fibrillation, based on how long the fibrillation lasts:

paroxysmal atrial fibrillation: a form that comes and goes and usually stops within a couple of days with no treatment
persistent atrial fibrillation: a longer-lasting form that typically lasts longer than a week, but can resolve more quickly if treated
permanent atrial fibrillation: a form that is present all the time

The AFA/ACE report estimates that 1.5 million people in the UK have atrial fibrillation but that currently up to half of these cases remain undiagnosed.

What are the signs of atrial fibrillation?

Not all people with the condition will show symptoms of atrial fibrillation. In people who do have symptoms, these can include:

breathlessness
palpitations
fainting or dizziness
chest discomfort

With atrial fibrillation you may also have an irregular pulse.

How is atrial fibrillation currently diagnosed?

NICE recommends that people going to their doctor with any of the signs described above, or who have had a stroke or mini-stroke, should have their pulse checked manually to see if it’s irregular. People who have no symptoms may also have an irregular pulse detected just by chance, when visiting their doctor for another reason.

NICE suggest that an electrocardiogram (ECG) should be performed in all patients who have an irregular pulse and are suspected to have atrial fibrillation, even without symptoms.

What are the risks associated with atrial fibrillation?

Blood does not flow smoothly out of the heart during an episode of atrial fibrillation, and this increases the risk of blood clots forming. Because of this, people with atrial fibrillation are at an increased risk of having a stroke (where a blood clot lodges in the brain). Atrial fibrillation can also lead to heart failure.

The factors reported to increase the risk of stroke in people with atrial fibrillation include:

being female
being elderly
having previously had a stroke or TIA (mini stroke)
having high blood pressure
having heart failure or valvular heart disease
having diabetes
having vascular disease

How is atrial fibrillation treated?

There are various ways of treating atrial fibrillation, depending on the form it takes and other factors. Possible treatments include drug treatment, electrical treatments and surgery. People with atrial fibrillation who also have other risk factors for stroke should also take an anticoagulant to reduce their risk.

What does the report say about checking patients’ pulses?

The AFA and ACE recommend the following measures:

a national screening programme for atrial fibrillation that targets those at risk of atrial fibrillation and stroke
an audit in general practices to identify and flag up patients at risk of atrial fibrillation
manual pulse checks on all patients at risk of atrial fibrillation when they visit their GP’s surgery
immediate access to an electrocardiogram (ECG) for patients in whom atrial fibrillation is suspected
readily available 24- and 48-hour heart monitoring, to diagnose intermittent atrial fibrillation

What is the current policy on atrial fibrillation screening?

Screening is a process of identifying apparently healthy people who may be at an increased risk of a disease or condition. The screening process does not include testing people who already have symptoms.

The UK National Screening Committee (NSC) advises government ministers and the NHS on all aspects of screening and supports implementation of screening programmes. National screening programmes for healthy people can be expensive and potentially lead to an increase in investigations and treatments for people who might not necessarily have developed symptoms or problems. The committee regularly assesses the evidence about new screening programmes that could be offered, to determine whether they would do more good than harm at a reasonable cost.

Currently, the NSC’s recommendation is that routine screening for atrial fibrillation in adults should not be offered. This policy is being reviewed. This review involves identifying any relevant new evidence published since the policy was made and assessing whether this evidence suggests that the policy should be changed. The review began in January 2010 and is expected to be completed by March 2012.

What else does the report call for?

The AFA and the ACE’s extensive report also calls for:

ways to increase GP motivation to follow international guidelines on how atrial fibrillation should be managed
a national public and patient education campaign to improve detection of atrial fibrillation and promote patient empowerment, using existing materials
equal access to atrial fibrillation treatments and services for all NHS patients, regardless of location
an atrial fibrillation education campaign for GPs
government support for research into the causes, prevention, and treatment of atrial fibrillation