Surgery has many well defined risks–we perform procedures when the benefits far outweigh the risks. As healthcare providers, it is our job to carefully discuss the risks and benefits of any medical procedure with our patients prior to the planned procedure and make sure that they understand what we are doing, why we are doing it and what our ultimate goals include. We often discuss bleeding, infection, and other common post operative risks and then other risks that are specific to the particular procedure being performed. Now there may be a new perioperative clinical marker–atrial fibrillation–that can identify patients at risk for other complications such as stroke, long after discharge from the hospital. Atrial fibrillation is the most common heart rhythm problem in the entire world and is associated with stroke in patients who are at risk.
This past week the Journal of the American Medical Association published a new study examining both the incidence of atrial fibrillation after ANY surgery as well as the conferred risk of stroke. The study involved over 1 million patients and the results were quite alarming–nearly 28K patients had peri-operative atrial fibrillation and of those, almost 14K patients experienced strokes that occurred after discharge. Even more disturbing was the fact that the rate of atrial fibrillation was even higher in non cardiac surgery patients (as compared to those undergoing cardiac surgery). Many surgical patients may be discharged without knowing that they have atrial fibrillation or that they are at risk. Some may present with cryptogenic strokes and suffer life changing devastation. The data is very clear about the prevention of stroke in atrial fibrillation. Based on a risk score (known as the CHADS2-vasc) we are able to quickly calculate and assess risk for stroke (based on several common predisposing factors) and appropriately choose an anticoagulant for each patient. It is also clear that anticoagulation in high risk populations reduce stroke rates significantly.
There is no doubt that atrial fibrillation results in significant morbidity and mortality in the US today. According to data from Circulation published in 2013, one in every 19 deaths is due to atrial fibrillation related stroke and nearly $37 billion dollars is spent on patient care due to this disease. Even more disturbing is the fact that many patients with atrial fibrillation are totally asymptomatic and may not even know they have the arrhythmia at all—many patients’ first presentation with atrial fibrillation is sadly a presentation with a devastating stroke. The recent article in JAMA further emphasizes the negative impact that silent atrial fibrillation can have on patients. As clinicians, we remain vigilant for the presence of atrial fibrillation and often we are able to identify and screen those at high risk–however, many patients are missed and preventative therapy with anticoagulation is never prescribed.
What is the Answer? How can we better screen asymptomatic patients for atrial fibrillation in a cost effective, broad based way?
The Alive Cor iPhone EKG application and device is the first of its kind. It is an FDA approved device that can record a single lead electrocardiogram directly from your fingertips, display the tracing on the iPhone screen and transmit the tracing to the cloud for review. The device is now available direct to consumers for purchase and no longer requires a physician prescription. In May, a clinical trial was published that demonstrated that the Alive Cor device could be used to easily screen large groups of consumers for atrial fibrillation in a cost effective way. In the study, which was published in May in Thrombosis and Haemostasis, investigators screened 1000 asymptomatic pharmacy customers for atrial fibrillation using the Alive Cor device and found that 1.5% of them actually had atrial fibrillation upon screening. The cost effectiveness per stroke saved in the US was estimated to be a cost savings of nearly 20%.
Given the high prevalence of both symptomatic and asymptomatic atrial fibrillation worldwide, it is essential that healthcare providers strive to do a better job screening for this sometimes silent disease. The identification of patients at risk for stroke from atrial fibrillation (and subsequent anticoagulation) is the best way to reduce both the cost and devastating morbidity and mortality associated with the disease. With technology such as the AliveCor device readily available to both patients and clinicians it is essential that we begin to utilize this device for massive, cost effective screening efforts. As healthcare reform shifts focus on prevention of costly disease, we must continue to focus on improving screening and care for those at highest risk.