HASTE-Network In Guildford and Surrey. Background. Arrhythmia Screening in Primary care to reduce Stroke. HASTENinGS 2013

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1 HASTE-Network In Guildford and Surrey Arrhythmia Screening in Primary care to reduce Stroke Background Atrial Fibrillation is a very common heart condition which causes 15-20% of all Stroke. Its incidence rises with age and is therefore set to increase over the next 20 years. In Surrey there are 195,101 people over 65 years of age and it is estimated of these at least 4000 have un-diagnosed permanent atrial fibrillation. The majority of these people are not taking anticoagulants that could protect them from having a stroke. There are two types of atrial fibrillation: transient- where the abnormal rhythm lasts between minutes and days and permanent atrial fibrillation. The former group is especially high risk for developing stroke because clots form after only 24 hours of atrial fibrillation which can then detach as normal rhythm and atrial wall movement are restored. In any individual patient, episodes of transient atrial fibrillation usually lengthen in duration over several years- so a patient with intermittent atrial fibrillation will often eventually move on to have permanent atrial fibrillation. Detection of AF in this high risk group of patients is challenging because many patients are not aware that they have atrial fibrillation or have transient symptoms that cannot easily be diagnosed by GPs. To make matters even more difficult, many healthy people have an erratic pulse caused by an innocuous ectopic beats (which are a variant of normal and carry no risk), so any public or GP pulse checking campaign has the potential for creating many false alarms: screening large groups of people with specialized equipment is the only effective way to detect and treat the problem accurately. Transient atrial fibrillation lasting minutes to hours is hard to diagnose because the electrocardiogram is completely normal between attacks- and diagnosis is only secured by making numerous recordings of heart rhythm over time. In hospital practice this is only achieved by using ambulatory ECG recorders for a week, an implantable recorder (ILR) for 2 years or perhaps by training the patient to take daily rhythm recordings over several weeks. Because very few general practices have the necessary equipment to diagnose intermittent atrial fibrillation- traditional healthcare requires all suspected cases to be referred to a Hospital. Yet only a small proportion of people with an irregular pulse turn out to have atrial fibrillation so a large pulse awareness and screening program would generate many thousands of extra referrals that could overload Hospital resources. Our research project will therefore test a new diagnostic method which involves going out to communities with simple heart rhythm recorders suitable for screening larger numbers of people.

2 About us: HASTE and HASTE ACADEMY The Heart and Stroke Trust Endeavour (HASTE) is a Surrey based Charity that has already raised in excess of 1M to combat Heart disease and Stroke. It built the Cardiovascular HASTE wing at the front of the Royal Surrey County Hospital in Guildford 6 years ago and in July 2011 gifted 460,000 to the University of Surrey (UoS) to conduct AF Research. The HASTE Academy was set up as a separate UK Charity to handle Education. Its board of Trustees comprises Chairman Mr Gerald Bland, Cardiologists Dr Edward Leatham, Matt Fairclough, GP Dr Graham Tyrrell, and Mr Edward Hultley who will be helping to organise Public and GP education program, to be launched by HASTE Academy. The relationship between these groups is shown in Fig 1. Funds donated to Haste and Haste Academy are being used by Royal Surrey NHS Trust and University of Surrey Research Teams to set up and test community based AF detection Hubs in Surrey. A team of Arrhythmia Nurses and one Research Fellow will be appointed to run the project over 2 years starting in We will research whether a new Arrhythmia Network (called the HASTE-Network in Guildford and Surrey or HASTENinGS), combined with a public and GP education programme run by HASTE ACADEMY improves the detection and preventative treatment of high-risk AF patients, thereby reducing the number of people suffering AF-related Stroke. The screening programme has been designed in association with Management Consultants and local GP commissioning groups, and Surrey Cardiac Network (Liz Petrou), so that if the project is successful in reducing Stroke, its running costs could potentially be adopted by the new GP commissioning groups. The HASTE Research Steering group comprises Professor Chris Fry (UoS), and three Cardiologists: Dr Mark Norman, Dr Riyaz Kaba and Edward Leatham who is also a HASTE Trustee HASTE ACADEMY Public and GP education campaign Although there are pulse check campaigns already run by BHF and The Arrhythmia Alliance and AFA, there is still poor public understanding about AF and the importance of regular pulse checks over the age of 65 yrs, so Haste Academy will coordinate a local intensive PR campaign to increase public awareness. This will include Poster and Media Campaign Interactive website featuring blogs, forums and social media profiles Radio and local press articles Because many GPs do not have access to ECG monitoring equipment, there are concerns that once launched, the public education campaign may lead to an increase in referrals to local hospitals for arrhythmia monitoring- which may overload existing services. For this reason the campaign will only be launched once the HASTENinGS community clinics are in place.

3 Methods for Community Screening- a charity-funded initiative that will run for two years April March Guildford and Waverly GPs will be asked to refer eligible patients who are 65yrs or older to the HASTE ACADEMY office by sending a/ 12 lead ECG and b/ arrhythmia clinic proforma via NHS . Referral criteria are: palpitations, actual or suspected intermittent or suspected arrhythmia, where further risk stratification or ambulatory ECG monitoring are required. These referrals will need to be outside choose and book and RSCH standard referral systems, since it is, in effect a community screening service- see Fig 2 and Fig Each referral will be examined by one of the HASTE funded Arrhythmia research nurses who will undertake telephone triage with each patient. In a small proportion of cases this phone triage will lead to the referral being directed to Cardiologists at the patients preferred local DGH but it is expected in the majority of cases however, to lead to the nurse making an appointment for a 7 day ECG recorder (R test) fitted at one of four HASTE community clinics held in a GP surgery. Where necessary, referrals can be discussed with one of the cardiologists. If phone triage cannot be arranged, the nurse will write to the GP to ask that the patient is referred to Cardiologist using traditional referral methods 3. The Nurse will use bespoke software (designed by Bluespier) to Register and collect details on all cases, which can also be used for the initial risk assessment. This will be also used as a long term AF Register. The software will show all available GP outreach clinics across Surrey, and will allow ECG devices to be allocated to a particular patient (ie keeps accurate stock for efficient use) 4. By the end of the Triage phone assessment, the Nurse and patient agree a time and date, which is then confirmed in writing by the HASTE Admin support team 5. On the day of the Outreach appointment, the Nurse will be handed a box containing all equipment that has been allocated (where all devices are pre programmed), so that each test simply needs to be taken from the box and fitted in the outreach clinicusually based in a GP Surgery ECG room 6. The Arrhythmia Nurse will see each patient and use a PC or IPAD2 connected to our Data centre to collect clinical data instead of using the GP EPR.. This system can capture high resolution ECG images onto the EPR as well as Consultation information- important for cases that need Cardiologist input 7. An ambulatory ECG device can be fitted and return date/meeting agreed. All patients will be offered longer term monitoring as part of the research project. 8. All Portable ECG analysis will be done within HASTE ACADEMY Offices by the Nurses supervised by Cardiologists. 9. The Arrhythmia Nurse will then identify any cardiac arrhythmia, provide a written risk assessment (CHADVASC) and recommendation to the referring GP 10. Where significant arrhythmias or ECG abnormalities requiring our expertise are detected, the Nurse can recommend referral to the Arrhythmia service or in some cases will use their discretion to pass the referral on directly. Many GPs have indicated that they would be happy for the Arrhythmia Nurse to pass their referral onto us at RSCH if appropriate- ie only one referral needs to be made by the GP The research project will measure number of patients seen, outcomes and impact of any intervention, along with proportion of cases referred to Arrhythmia clinics and proportion of High risk (CHADVASC> 3) cases started on anticoagulants following referral.

4 Expected Value of Results We expect to identify many people in atrial fibrillation or having transient atrial fibrillation (so called paroxysmal atrial fibrillation). Although some will be at low risk of stroke, many will be at high risk and can be offered anticoagulant medication to prevent Stroke.

5 Fig 1 Funding and Governance Fig 2 The Overview of the HASTENinGs Research Project

6 HASTENinGS 2013 Figure 3 shows the existing protocol for GPs to manage suspected cases of AF. The Haste logos show a/ where the GP might expect to refer a patient to the HASTENinGS team and b/ where additional information for patients can be obtained.