Vroegopsporing van voorkamerfibrillatie in de eerstelijn Wat is de accuraatheid van MyDiagnostick bij patiënten ouder dan 65jaar in de eerstelijnsgezondheidszorg? Seminariewerk 4 de master geneeskunde D. Lapeire, S. Stalpaert, K. Tavernier en B. Thaels
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Vroegopsporing van voorkamerfibrillatie in de eerstelijn
Wat is de accuraatheid van MyDiagnostick bij patiënten ouder dan 65jaar in de eerstelijnsgezondheidszorg?
Seminariewerk 4de master geneeskundeD. Lapeire, S. Stalpaert, K. Tavernier en B. Thaels
1. Algemeen: VKF •Voorkamerfibrillatie:
Tachyaritmie van de atria met ongecoördineerde activatie van de voorkamers▫Ectopische foci in de atria▫Abnormaal atriaal weefsel▫Veranderingen in de atriale elektrofysiologie
(verkorten refractaire periode)
•Evolutie: intermittent → persisterend
2. Waarom screening? Wilson-Jungner criteria:
•Belangrijk gezondheidsprobleem▫2e meest frequente HRstoornis in klinische
praktijk Prevalentie: 0,4-1%,
toenemend met de leeftijd (5-6% bij 65+)•Potentieel ernstige gevolgen
- Afwezigheid consistente P-toppen- RR-intervallen zonder repititief patroon- Variabel atriaal activatie-interval, meestal
<200ms
•Kosten-baten
Afhankelijk van prevalentie niet-gediagnosticeerde VKF→ belang van zoeken naar hoog-risicogroepen!
•Risicofactoren: deze maken opsporing en behandeling in een latent stadium mogelijk▫ Leeftijd▫ Geslacht▫ Arteriële hypertensie▫ Diabetes mellitus▫ Adipositas▫ Hyperthyroïdie▫ Congestief hartfalen▫ Kleplijden▫ Familaal voorkomen VKF
•Werkcijfers met geschatte prevalentie van 6% → mogelijks onderschatting; we missen:▫Intermittente VKF-ers▫Asymptomatische VKF-ers→ nood aan systematische screening!!
•Convenience sample▫+ : in weinig tijd veel patiënten▫- : niet representatief voor de populatie
•Alle aflezingen binnen hetzelfde consult→ wat bij thuismonitoring met aflezingen op verschillende dagen?
•Kosten-baten▫Afhankelijk van prevalentie niet-
gediagnosticeerde VKF→ gebruik Framingham risicoscore ?
Literatuurreferenties {1} Wilson JMG, Jungner G. The principles and practice of screening for disease. WHG Public Health papers. Geneva: World Health Organization, 1968:34.{2} John Camm, Gregory Y.H. Lip (UK), Raffaele De Caterina, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation.European Heart Journal (2012) 33, 2719–2747{3} K. Harris, D. Edwards, J. Mant. How can we best detect atrial fibrillation? J R Coll Physicians Edinb. 2012;42(suppl 18):5-22{4} Vias Markides, Richard J. Schilling. Atrial fibrillation:classification, pathophysiology, mechanisms and drug treatment. Heart 2003 August; 89(8):939-943.{5} Perula-de-Torres, Martinez-Adell, Gonzalez-Blanco et al. Opportunistic detection of atrial fibrillation invsubjects aged 65 years or older in primare care: a randomised clinical trial of efficacy. DOFA-AP study protocol, BMC Family Practice 2012, 13:106{6} Miyasake Y, Barnes ME, Gersh BJ, Cha SS, Bailey KR, Seward JB, et al. Coronary ischemic events after firstbatrial fibrillation: risk and survival. Am J Med 2007; 120:357-63.
{7} Wang TJ, Larson MG, Levy D, Vasan RS, Leip EP, Wolf PA, et al. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation 2003; 107:2920-5.{8} Stephen Morgan, David Mant. Randomised trial of two approaches to screening for atrial fibrillation in UKgeneral practice. British Journal of General Practice, May 2002; 373:380.{9} B.F. Gage, A.D. Waterman, W. Shannon, et al. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285:2864-2870.{10} G.Y. Lip, R. Nieuwlaat, R. Pisters, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk facto-based approach: the Euro Heart Survey on AtrialFibrillation. Chest. 2010;137:263-272.{11} R. Nieuwlaat, S.B. Olsson, G.Y. Lip, et al. Guidelineadherent antithrombotic treatment is associated withimproved outcomes compared with undertreatment in high-risk patients with atrial fibrillation: the Euro heartSurvey on Atrial Fibrillation. Am heart J. 2007;153:1006-1012.{12} National Collaborating Centre for Chronic Conditions. Atrial fibrillation: national clinical guideline for management in primary and secondary care. London: Royal College of Physician; 2006.
{13} Polychronis E. Dilaveris, Elias J. Gialafos, Skevos K. Sideris, Artemis M. Theopistou, George K. Andrikopoulos et al. Simple electrocardiographic markers for the prediction of paroxysmal idiopathic atrial fibrillation. Amheart J 1998; 135:73 3-8.{14} Benjamin EJ, Levy D, Vaziri SM, D’Agostino RB, Belanger AJ, Wolf PA. Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. JAMA 1994 Mar 16; 271(11):840-4.{15} S Carley, S Dosman, S R Jones, et al. Simple nomograms to calculate sample size in diagnostic studies. merg Med J 2005;22:180–181.{16} Renate B. Schnabel, Lisa M. Sullivan, Daniel Levy, et al. Development of a Risk Score for Atrial Fibrillation in the Community; The Framingham Heart Study. Lancet. 2009 February 28; 373(9665): 739–745{17} Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting strokeand thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey onAtrial Fibrillation. Chest 2010;137:263–272.{18} G. Mancia, G. De Backer, A. Dominiczak, et al. The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC); European Heart Journal (2007) 28, 1462–1536{19} Prineas R, Crow R, Blackburn H. The Minnesota Code Manual of Electrocardiographic Findings. John Wright – PSG, Inc. Littleton, MA, June 1982.
• {20} P. Zimetbaum. Antiarrhythmic Drug Therapy for Atrial Fibrillation. Circulation. 2012;125:381-389.
• {21} J. Wiesel, S. Abraham, F.C. Messineo. Screening for asymptomatic atrial fibrillation while monitoring the blood pressure at home: trial of regular versus irregular pulse for prevention of stroke (TRIPPS 2.0). Am J cardiol. 2013. http://dx.doi.org/10.1016/j.amjcard.2013.01.331.
• {22} J. Wiesel, L. Fitzig, Y. Herschman, et al. Detection of atrial fibrillation using a modified microlife blood pressure monitor. Am J Hypertens. 2009;22:848-52.
• {23} M. Lewis, D. Parker, C. Weston, M. Bowes. Screening for atrial fibrillation: sensitivity and specificity of a new methodology. British Journal of General Practice. January 2011;61:38-9.
• {24} S. Somerville, J. Somerville, P. Croft, et al. Atrial fibrillation: a comparison of methods to identify cases in general practice. Br J Gen Pract. 2000;50:727-9.
• {25} J. Mant, DA Fitzmaurice, FD Hobbs, et al. Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial. BMJ 2007;335:380.