Atrial fibrillation: are we losing touch with the diagnosis?

As every GP knows, we are life-saving superheroes. We put on our superhero capes every day, we fly to work (Is it a bird? Is it a plane?) and we save lives. Between us, we save literally thousands of lives every day. But because we save these lives in a less immediate and tangible way than our colleagues in A&E or ITU, our life-saving work is less obvious and therefore less celebrated.  We save these lives in many different ways, for example through the early diagnosis of diseases such as cancer, through health promotion and lifestyle change, or via medications appropriately prescribed for cardiovascular prevention. But because we never see the cancer or cardiovascular death that we prevented, because it never happened, our life-saving role is easy to forget. Last week I spoke with a very well 90-year-old patient, still independent and still living at home, in whom I opportunistically diagnosed atrial fibrillation 10 years ago. If I had not made that diagnosis, would she have had a stroke and lost her independence? Would she have died? We don’t know, but what we do know is that on a population level opportunistic diagnosis and appropriate management and anticoagulation of atrial fibrillation prevents strokes and saves lives. 

Last week NICE published their newly updated guideline on AF NICE 2021, NG 196. Interestingly the guideline starts with the recommendation 1.1.1. ‘perform manual pulse palpation to assess for the presence of an irregular pulse if there is a suspicion of atrial fibrillation’. What they do not mention, is that this is kind of hard to do down the phone! Now that 90% of our consultations are remote ones, how will we detect silent AF? If we speak to patients and they are symptomatic with breathlessness or palpitations, of course, we shall bring them in to examine them. However, in my experience virtually all the diagnoses I have made of AF over the years have been of silent AF, a diagnosis opportunistically made by touch, feeling the pulse of the patient sitting in front of me. Younger patients tend to present with symptomatic AF. Older patients, and those most likely to suffer a stroke, tend to have silent AF. In the absence of a screening programme, how then are we going to pick these up when we are not seeing patients face to face and feeling their pulse? 

Back in 2016 an editorial in the Lancet entitled Atrial fibrillation and stroke: unrecognised and undertreated Lancet2016;388:731 started with: ‘When did your primary care physician last palpate your wrist to check for a regular heart beat? This simple action, followed by an ECG if the heart is irregular, might be crucial in preventing death or disability from ischaemic stroke, heart failure or myocardial infection.’  When indeed. We have heard a lot over the past year of the impact of the pandemic on delayed cancer diagnoses and excess cancer deaths. In the absence of a screening programme, if we are still relying on opportunistic examination to detect AF are we likely to see a similar increase in adverse outcomes related to AF? 

We are covering all the crucial points of the new NICE guidelines in our new Hot Topics GP Update course, and also the management of acute AF in our Urgent Care course. Both of these are available as upcoming live events and of course on-demand on NB Plus. The new NICE guidelines for AF are welcome, but what will be the point if we are quite literally losing touch with the diagnosis?