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Atrial Fibrillation PCP Perspective
PCP Perspectives: Key Takeaways From the 2023 Atrial Fibrillation Guideline Updates

Released: June 04, 2024

Expiration: June 03, 2025

Alpesh N. Amin
Alpesh N. Amin, MD, MBA, MACP, MHM, FRCP (Lond), FACC, FHFSA, CPE
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Key Takeaways
  • Best practices in screening for atrial fibrillation include accurately assessing patients’ annualized risk of a cardioembolic stroke, which can be accomplished through validated tools like the CHA2DS2-VASc score, assessing risk factors, and using wearable ECG technologies.
  • Use of these technologies should be considered based on patient needs/preference and what further information is needed to diagnose atrial fibrillation.
  • Join our live, virtual “Ask the Expert” webinar session on July 25, 2024 to have your questions on updates in atrial fibrillation management answered by expert cardiology faculty.

In terms of clinical guidelines and early staging of atrial fibrillation (AF), primary care providers (PCPs) are often the first healthcare professional to see and diagnosis AF in their daily practice. Several important questions on the role of PCPs in AF screening and management were addressed in the recently updated AF guidelines.

Implementing Technology to Enhance Screening
In 2019, I was a coauthor for the Heart Rhythm Society and American College of Physicians’ AF screening and education initiative. We used a personal and wearable ECG device to screen patients and felt that using devices like this may enhance patient engagement and screening programs.

At that time, we completed a study of 772 participants who were screened for AF at 5 participating sites in the primary care setting. The mean age was 65 years, 28% were 75 years old or older, and 67% were female.

Further, approximately 67% had a CHA2DS2-VASc score of 2 or higher. After screening, we found that the majority of participants (86%) were “normal,” but 11% had unclassified findings and 2.2% had possible AF. Of importance, our findings show that participants had a significant knowledge deficit around stroke risk and AF before their screening, and they felt that their awareness increased significantly because of our screening process.

For patients who have an elevated risk of stroke secondary to AF (eg, CHA2DS2-VASc score of 1 or greater), PCPs should have some organized screening process that includes a wearable device to confirm the presence of AF. Of note, studies have shown that approximately 20% of patients globally have undiagnosed AF. And we know that AF increases one’s risk of stroke, which is often the first clinical manifestation of this arrhythmia. Therefore, it is critical from this perspective that PCPs utilize wearable technologies to better diagnose AF.

The CHA2DS2-VASc is one validated tool for measuring cardioembolic stroke risk, however, there are risk factors not accounted for in this tool to consider when determining if patients should be screened for AF. These include patients with family history of AF, lone AF, or thyrotoxicosis. PCPs should also think about the other risk factors patients may have in their family history, such as obesity and thyroid disease. PCPs should understand when to suggest using a continuous device or what I call a “spot-check device” which can be used with patients’ smartphones as prescribed.

How should these devices be used? The continuous tracking devices really are for patients who are having symptoms but are not sure when they occur, and you want to manage it with continuous monitoring. But the final decision boils down to patients, their insurance status, and what is affordable vs what you are monitoring for.

Refer to Cardiology or Initiate Therapy?
When determining whether to initiate therapy or refer to a cardiologist first for those with confirmed AF, the choice depends on the situation and patients’ comfort level. We, as PCPs, want to try to get patients’ heart rate and rhythm in control. So, if you are having trouble doing that, then you will need to refer patients to cardiology. But if you have it under control in the primary care setting, then great; you can manage the patient and maintain their heart rhythm.

In terms of therapy, anticoagulation is a must, especially as patients’ risk increases (eg, annualized risk of ≥2% as estimated by the CHA2DS2-VASc or another tool). The guidelines are clear in terms of when to initiate anticoagulation therapy, and they continue to support prescribing direct oral anticoagulants (DOACs) over warfarin unless patients have a mechanical heart valve, mitral stenosis, or if a DOAC is otherwise contraindicated. Generally, patients with a score of 1 or greater should receive anticoagulation unless the risk of bleeding outweighs the benefit. Once initiated, it is imperative that the prescriber uses evidence-based dosing for each patient and avoids empirically adjusting doses higher or lower indiscriminately. The updated guidelines site under- and over-dosing patients inappropriately as a key issue to correct in optimizing care.

Finally, determining the correct therapy is also going to come down to patient needs, costs, and insurance status. I have not had too much of a problem with patients accessing DOACs in my clinical practice, but there may be some insurance companies that are a little bit more challenging.

Your Thoughts?
As a PCP, do you recommend wearable technologies or devices to screen patients who are at risk for AF? You can get involved by answering the polling question and posting a comment below.

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As a PCP, how often do you discuss wearable technologies or devices with patients for AF screening?

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