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Awareness campaigns of atrial fibrillation as an opportunity for early detection by pharmacists: an international cross-sectional study

Abstract

Atrial fibrillation (AF) accounts for up to one third of strokes, one of the lead mortality causes worldwide. The European Society of Cardiology guidelines recommend opportunistic screening as a means to increase the odds of early detection and institution of appropriate treatment according to risk factors identified. However, in most countries there are various barriers to effective uptake of screening, including low awareness. The Atrial Fibrillation Association is a patient association engaged with raising awareness of AF. Establishing a partnership with the International Pharmacists for Anticoagulation Care Taskforce, we set as goals to test a model for raising awareness of AF involving pharmacists globally; and to identify barriers and enablers to its implementation. A cross-sectional study was conducted during the Arrhythmia Alliance World Heart Rhythm Week. Pharmacists from 10 countries invited individuals (≥ 40 years; without anticoagulation therapy of AF) to participate in the awareness campaign. Participants agreeing were engaged in the early detection of AF (EDAF) using pulse palpation. Individuals with rhythm discrepancies were referred and prospectively assessed to have information on the proportion of confirmed diagnosis, leading to estimate the detection rate. Interviews with country coordinators explored barriers and enablers to implementation. The study involved 4193 participants in the awareness campaign and 2762 in the EDAF event (mean age 65.3 ± 13.0), of whom 46.2% individuals were asymptomatic, recruited across 120 sites. Most common CHA2DS2-VASc risk factor was hypertension. Among 161 patients referred to physician, feedback was obtained for 32 cases, of whom 12 new arrhythmia diagnoses were confirmed (5 for AF, 2 for atrial flutter), all among elders (≥ 65 years). Qualitative evaluation suggested a local champion to enable pharmacists’ success; technology enhanced engagement amongst patients and increased pharmacists’ confidence in referring to physicians; interprofessional relationship was crucial in success. This study suggests pharmacists can contribute to greater outreach of awareness campaigns. Effective communication pathways for inter-professional collaboration were suggested enablers to gain full benefits of EDAF.

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Data availability

The data that support the findings presented in this study are available from www.ipact.org. Data are available from the authors upon reasonable request.

Abbreviations

A-A:

Arrhythmia Alliance

AF:

Atrial fibrillation

AF Assoc:

Atrial Fibrillation Association

CHA2DS2-VASc:

Atrial Fibrillation Stroke Risk (Congestive heart failure history; hypertension; advanced age; diabetes; stroke or thromboembolism history; vascular disease history; sex)

CHF:

Congestive heart failure

DM:

Diabetes mellitus

ECG:

Electrocardiogram

EDAF:

Early detection of atrial fibrillation

ESC:

European Society of Cardiology

GPs:

General practitioners

iPACT:

International Pharmacists for Anticoagulation Care Taskforce

MI:

Myocardial infraction

UK:

United Kingdom

HIV:

Human immunodeficiency virus

PAD:

Peripheral artery disease

SD:

Standard deviation

SOB:

Shortness of breath

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Acknowledgements

The authors acknowledge all individuals who took the pulse checks and engaged in the awareness initiative. We also thank all motivated pharmacists who collaborated in data collection and contributed to raise awareness across the globe. Specifically for Switzerland and Portugal, we acknowledge the contribution of two pharmacy groups, respectively Top Pharm and Holon. Finally, we acknowledge Dr. Jagjot Chahal for the critical revision of this manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author information

The manuscript was originally drafted by FAC, reviewed and enriched by KML, SA and LN, subsequently critically reviewed by all authors and proof read for English by native co-authors, namely SA, LN, TL and BF. All named authors contributed substantially to the study conception and design (FAC, SA, TL, BF), data acquisition (RV, MCC, EP, DG, KH, VL, ST, KML), analysis and manuscript writing (FAC, KML, LN, SA). All gave final approval and agree to be accountable for all aspects of work ensuring integrity and accuracy.

Correspondence to Filipa Alves da Costa.

Ethics declarations

Conflict of interest

T. Lobban is the Founder and CEO of AF Assoc and Arrhythmia Alliance, a non-profit registered charity aiming to raise awareness of atrial fibrillation (AF), which receives funding from various sources, including donations, fundraising, grants, and trusts. Most of the authors are members of International Pharmacist for Anticoagulation Care Taskforce (FAC, VL, SA, MCC, DG, RV, JP, KML), an organization representing pharmacists with interests in anticoagulation, under the statutes of DRM-Foundation. DRM-Foundation has received funding in the past from Bayer Global and from Pfizer, Canada. S. Antoniou received personal fees and/or non-financial support from Bayer, Boehringer Ingelheim, Daiichi Sankyo and BMS/Pfizer related to AF anticoagulant management. B. Freedman reports grants to the institution, for investigator-initiated studies from Pfizer/BMS, and Bayer and Boehringer Ingelheim personal fees and/or non-financial support from Bayer, Boehringer Ingelheim, and BMS/Pfizer, related to screening for AF. None of these companies had any influence on the study design, conduct or review of results presented; neither did they provide any funding for the development of the study described.

Ethics approval

The Project was approved by Egas Moniz Ethical Review Board, Portugal (No. 319), Univerzita Karlova Eticka Komise, Czech Republic (No. 911), Barts Health NHS Trust Ethics Committee (No. 10357), the National Institute of Pharmacy and Nutrition in Hungary (No. 29517) and The Chinese University of Hong Kong Ethics Committee (CRE-2014.012). The remaining countries after consulting with their Local or National Committees, because the law mentions that as long as the activity is within the normal scope of pharmacy practice data may be used for observational studies, it was considered that the precedent decisions were valid. As an example, regulatory law for observation studies in France states that ethical approval by an Ethics Committee is not mandatory when looking at healthcare professional practices (Article R1121-1-II of the Public Health Code, Decree No. 2017-844, 9th May 2017; available at https://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000034634217&categorieLien=id. In fact, the trend to use anonymous patient data as part of the provided care and support and acknowledge its use is being adopted in many countries by various research organisations following recommendations from patients themselves, quoting “This work uses data provided by patients and collected by the NHS as part of their care and support” available at www.usemydata.org.uk.Data collection was also notified to the competent bodies (e.g. Comissão Nacional de Proteção de Dados, Portugal). Patients agreeing to the EDAF gave their written consent. Only in Spain, France and Hungary were oral consent considered sufficient by the national legislation, as long as the pharmacist clearly provided all information orally, which was ensured.

Informed consent

The informed consent included a section authorising publication of data in a compiled and anonymized format. The investigation conforms with the principles outlined in the Declaration of Helsinki [29].

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da Costa, F.A., Mala-Ladova, K., Lee, V. et al. Awareness campaigns of atrial fibrillation as an opportunity for early detection by pharmacists: an international cross-sectional study. J Thromb Thrombolysis (2019). https://doi.org/10.1007/s11239-019-02000-x

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Keywords

  • Atrial fibrillation
  • Awareness
  • Pharmacists
  • Pulse check
  • Early detection of disease