Atrial fibrillation (AF) causes a third of all strokes, but often goes undetected before stroke. Identification of unknown AF in the community and subsequent anti-thrombotic treatment could reduce stroke burden. We investigated community screening for unknown AF using an iPhone electrocardiogram (iECG) in pharmacies, and determined the cost-effectiveness of this strategy. Pharmacists performed pulse palpation and iECG recordings, with cardiologist iECG over-reading. General practitioner review/12-lead ECG was facilitated for suspected new AF. An automated AF algorithm was retrospectively applied to collected iECGs. Cost-effectiveness analysis incorporated costs of iECG screening, and treatment/outcome data from a United Kingdom cohort of 5,555 patients with incidentally detected asymptomatic AF. A total of 1,000 pharmacy customers aged ≥65 years (mean 76 ± 7 years; 44% male) were screened. Newly identified AF was found in 1.5% (95% CI, 0.8–2.5%); mean age 79 ± 6 years; all had CHA₂DS₂-VASc score ≥2. AF prevalence was 6.7% (67/1,000). The automated iECG algorithm showed 98.5% (CI, 92–100%) sensitivity for AF detection and 91.4% (CI, 89–93%) specificity. The incremental cost-effectiveness ratio of extending iECG screening into the community, based on 55% warfarin prescription adherence, would be $AUD5,988 (€3,142; $USD4,066) per Quality Adjusted Life Year gained and $AUD30,481 (€15,993; $USD20,695) for preventing one stroke. Sensitivity analysis indicated cost-effectiveness improved with increased treatment adherence. Screening with iECG in pharmacies with an automated algorithm is both feasible and cost-effective. The high and largely preventable stroke/thromboembolism risk of those with newly identified AF highlights the likely benefits of community AF screening. Guideline recommendation of community iECG AF screening should be considered. Previous Presentation: This study was presented in part as an oral presentation at the Cardiac Society of Australia and New Zealand Conference; 9 August 2013; Sydney, Australia, abstract published in Heart Lung Circulation 2013;22:S223. Trial registration: Australian New Zealand clinical trials registry: ACTRN12612000406808.

Background: Participation in cardiac rehabilitation (CR) benefits patients with coronary heart disease (CHD), yet worldwide only some 15–30% of those eligible attend. To improve understanding of the reasons for poor participation we undertook a systematic review and meta-synthesis of the qualitative literature. Methods: Qualitative studies identifying patient barriers and enablers to attendance at CR were identified by searching multiple electronic databases, reference lists, relevant conference lists, grey literature, and keyword searching of the internet (1990–2010). Studies were selected if they included patients with CHD and reviewed experience or understanding about CR. Meta-synthesis was used to review the papers and to synthesize the data. Results: From 1165 papers, 34 unique studies were included after screening. These included 1213 patients from eight countries. Study methodology included interviews (n = 25), focus groups (n = 5), and mixed-methods (n = 4). Key reasons for not attending CR were physical barriers, such as lack of transport, or financial cost, and personal barriers, such as embarrassment about participation, or misunderstanding the reasons for onset of CHD or the purpose of CR. Conclusions: There is a vast amount of qualitative research which investigates patients’ reasons for non-attendance at CR. Key issues include system-level and patient-level barriers, which are potentially modifiable. Future research would best be directed at investigating strategies to overcome these barriers.

Summary: Atrial fibrillation (AF) is associated with a significantly increased stroke risk which is highly preventable with appropriate oral anticoagulant therapy (OAC). However, AF may be asymptomatic and unrecognised prior to stroke. We aimed to determine if single time-point screening for AF could identify sufficient numbers with previously undiagnosed AF, to be effective for stroke prevention. This is a systematic review of clinical trials, by searching electronic medical databases, reference lists and grey literature. Studies were included if they evaluated a general ambulant adult population, using electrocardiography or pulse palpation to identify AF. We identified 30 individual studies (n=122,571, mean age 64 years, 54% male) in nine countries. Participants were recruited either from general practitioner and outpatient clinics (12 studies) or population screening/community advertisements (18 studies). Prevalence of AF across all studies was 2.3% (95% CI, 2.2–2.4%), increasing to 4.4% (CI, 4.1–4.6%) in those ≥65 years (16 studies, n= 27,884). Overall incidence of previously unknown AF (14 studies, n=67,772) was 1.0% (CI, 0.89–1.04%), increasing to 1.4% (CI, 1.2–1.6%) in those ≥65 years (8 studies, n= 18,189) in whom screening setting did not influence incidence identified. Of those with previously unknown AF, 67% were at high risk of stroke. Screening can identify 1.4% of the population ≥65 years with previously undiagnosed AF. Many of those identified would be eligible for, and benefit from OAC to prevent stroke. Given this incidence, community AF screening strategies in at risk older age groups could potentially reduce the overall health burden associated with AF.

Coronary heart disease (CHD) is a leading cause of death globally. Despite proven health benefits and international recommendations, attendance at cardiac rehab...