NICE guidelines will delay AF diagnosis: AF Association welcomes the new National Institute for Health and Care Excellence (NICE) guideline for atrial fibrillation (AF), the most common arrhythmia (heart rhythm disorder) and major cause of stroke. However, it is disappointed that the guideline requires a 12-lead electrocardiogram (ECG) to diagnose AF rather than a manual pulse rhythm check and use of modern mobile ECG technology, which has previously been approved by NICE. This will lead to a delay in diagnosis and, importantly, delay a person with AF receiving vital anticoagulation therapy to protect against AF-related stroke.1
The new NICE AF guideline, published today, states that people with AF should be offered a “personalised package of care” that covers all areas of management, from the need to Protect against AF-related stroke to providing information on support networks such as the AF Association. Importantly, the guideline calls for healthcare professionals, as part of providing personalised care, to adhere to NICE’s shared decision-making recommendations (as outlined in the 2012 “Patient experience in adult NHS services” guideline). This recommendation is in line with the AF Association’s recently published AF White Paper, which calls to put people with AF first.2 The AF White Paper — Put People First says that the focus of care should be on “the person with AF rather than the AF itself” and, like the new NICE guideline, says people with AF “should be signposted to organisations such as AF Association, who can provide medically approved information, advice, and support”.2
While AF Association is pleased the new guideline recognises the value of personalised care, it is concerned the guideline also states that a 12-lead ECG is necessary to make a diagnosis of AF. This could lead to a delay in diagnosis because not all GP clinics have access to a 12-lead ECG so someone with suspected AF may have to wait weeks, even months, before an appointment is available (maybe even longer with the current pandemic and the pressure the NHS is under with delayed appointments).
If you have AF, then you are five times more likely to have a stroke. AF-related strokes are known to be more disabling, more devastating and, in many cases, more likely to be fatal. It is vitally important that AF is detected quickly, and anticoagulation therapy is implemented to prevent clots forming in the heart — these clots can break away and travel to the brain, causing an AF-related stroke.
Public Health England’s Long Term Plan has made AF a priority to reduce the number of strokes each year in the UK. Delaying diagnosis by having to wait for a 12-lead ECG, when AF can be diagnosed in many with a simple manual pulse check and with approved mobile ECGs and apps, will lead to more devastating and fatal strokes.
AF Association’s AF White Paper states there are an increasing number of digital technologies that can produce a medical-grade single-lead ECG. This is supported by the 2020 European Society of Cardiology (ESC) AF guidelines, which state that “a single-lead ECG tracing of ≥30 seconds or a 12-lead ECG” can be used to diagnose AF.
Mrs Trudie Lobban MBE, Founder and CEO of AF Association, says: “We are glad that, in its new guideline, NICE acknowledges the importance of involving the person with AF in the decision-making process. As we advocate in our AF White Paper, people with AF must be empowered to take charge of their condition and be encouraged to use ‘self-care’ to improve their quality of life. However, we are worried by NICE’s recommendation that a 12-lead ECG must be used to diagnose AF as we believe that this may delay diagnosis and, potentially, may mean that a person with AF experiences a devastating AF-related stroke before they can receive the appropriate anticoagulation therapy.”
AF also causes heart failure, dementia, anxiety, and mental health issues, all leading to a poor quality of life. The quicker AF can be detected, the quicker anticoagulation therapy can be delivered thereby reducing the risk of AF-related stroke and patients with AF can begin receiving treatment to manage the symptoms of AF.
AF is often asymptomatic (no symptoms), and some people do not discover that they have AF until they have had a devastating AF-related stroke. AF Association campaigns for everyone to “Know Your Pulse to Know Your Heart Rhythm – it Could Save Your Life”. Opportunities should be taken — both in healthcare and non-healthcare settings — to Detect AF with a simple pulse check (manually or with digital tools). Anyone found to have an irregular heart rhythm pulse, or possible AF, should be encouraged to promptly seek medical advice for further investigation.
Professor Martin Cowie (Royal Brompton Hospital, King’s College London, UK), who was on the working group of the White Paper, says: “We need to Detect AF to Protect against AF-related stroke, but we also need to consider ways to Prevent AF in the first place. As we outline in the AF White Paper, ‘every contact should count’ — thus, opportunities should be taken during any healthcare professional contact to provide guidance, information, and support on a healthy lifestyle and risk factor management to optimise lifelong cardiovascular health.”
To download the AF White Paper — Put People First, visit: bit.ly/AFAWhitePaper To download NICE AF Guidelines, visit: https://www.heartrhythmalliance.org/aa/uk/guidelines
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