Patients’ views about screening for atrial fibrillation (AF): a qualitative study in primary care

Problem

Atrial fibrillation (AF) is a common heart rhythm irregularity, affecting around 10% of people aged over 65 in the UK. AF is associated with an increased risk of stroke, which is substantially reduced by anticoagulation. As a significant proportion of AF is paroxysmal and can be asymptomatic, it can often go undiagnosed. There has therefore been much recent debate about routinely screening for AF in the UK, with commissioned pilot schemes, ongoing large clinical trials, and the emergence pf inexpensive consumer single-lead electrocardiogram (ECG) devices that can be used to detect AF. There is however a sparsity of qualitative data in the literature on patient beliefs and attitudes towards screening for AF. Our aim was to explore patients’ views and understanding of AF and AF screening, in order to determine acceptability, and help inform future recommendations.

Approach

The current qualitative study was nested within the Screening for Atrial Fibrillation using Economical and Accurate TechnologY (SAFETY) study, a large primary care AF screening trial undertaken across three GP practices in the Wessex area. A convenience sample of 34 of the 418 trial participants not known to have AF from a single GP surgery were invited to take part in interviews, and 15 (44%) agreed to participate. A semi-structured interview guide was used flexibly to enable the interviewer to explore any relevant topics raised by the participants. Interviews were recorded, transcribed verbatim, and analysed using inductive thematic analysis in NVivo 10.

Findings

Of the 15 participants, four were male (27%) and the average age was 68 years. Participants generally had an incomplete understanding of AF and conflated it with other heart problems, or with raised blood pressure. Few acknowledged its association with risk of stroke or developing clots. With regards to their views on screening, many raised positive opinions regarding the potential for early detection and treatment of AF. Few participants considered anxiety and the cost of implementation, however none acknowledged potential harms associated with screening, such as potential for inaccurate results (e.g. false negatives), side effects of anti- coagulation treatment, or the risk and inconvenience of further investigations. The screening devices in the SAFETY trial were generally well accepted, and participants were generally in favour of engaging with prolonged screening if it were recommended to them by a healthcare professional.

Consequences

Our study highlights that there may be poor understanding (of both the nature of AF and potential drawbacks of screening) amongst patients who have been screened for AF. Further work is required to determine if resources including decision aids (which have been used successfully in other screening programmes) could address this important knowledge gap, improve clinical informed consent for AF screening.