Intermittent auscultation in obstetric practice in tertiary health facilities in Nigeria. Are we doing it correctly?

Background: Intermittent auscultation (IA) was the main method of foetal monitoring in Nigeria, with the pinard stethoscope more in use than the hand-held Doppler. Aim of the study to produce a guideline on IA, conduct an audit on its use and to give a recommendation for future practice. Methods: A mixed-method design-observational-descriptive, review and an audit carried out in tertiary centres in Rivers State, Nigeria. The WHO 2018, FIGO 2015 and other guidelines on IA were reviewed. Good practice points were extracted from the literatures and used to produce a guideline. 17 review criteria for the audit were chosen from the guideline and used to test 150 doctors, midwives and nurses. Data were analysed with Epi. info 2020. Results: A guideline on IA was created. Out of the 150 participants, correct answers to the questions were given as follows: foetal movements over the preceding 24 hours before IA, determination of foetal lie, assessment of presentation and position before IA and identification of point of application of foetal stethoscope on maternal abdomen by 121 (80.67%), 17 (11.33%) and 34 (22.67%) respectively; frequency of IA in the antenatal period, duration of IA and maternal pulse palpation during IA for 13-98 (8.67-65.33%), 121 (80%) and 0 (0%) respectively; in labour, questions on timing of IA, ruling out hypoxia in early labour, determination of the baseline FHR and recording of the findings on IA for 61-130 (40.67-86.67%); interval and duration of IA and management of abnormal findings in the antenatal period and in labour, interval and duration of IA at 2-18 (1.33-12%).Conclusions: The performance of IA by obstetric practitioners was poor; that may account for some of the wrong management plan in the antenatal and intra-partum periods. A quarterly or yearly drills on IA were therefore recommended.

Experiences with screening for atrial fibrillation: a qualitative study in general care

Background/IntroductionGuidelines recommend screening for atrial fibrillation (AF). Currently screening is not considered standard care among general practitioners (GPs).AimTo explore the experiences of primary care workers with different methods of screening for AF and with implementation in daily practice.Design & settingA qualitative study using semi-structured interviews with GPs, nurses and assistants, experienced with implementation of different methods of screening.MethodTwo independent researchers audio recorded and analysed interviews using a thematic approach. They asked participants about their experiences with the different methods used for screening AF and which obstacles they faced with implementing screening in daily practice.ResultsIn total 15 GPs, nurse practitioners and assistants from 7 different practices were interviewed. The GP’s office is suited for screening for AF, which ideally should be integrated with standard care. Participants considered pulse palpation, automated sphygmomanometer with AF detection and single-lead electrocardiography (ECG) as practical tests. Participants trusted pulse palpation over the algorithm of the devices. The follow-up of a positive test with a time-consuming 12-lead ECG hindered integration of screening. The single-lead ECG device reduces the need for immediate follow-up, because it can record a rhythm strip. The extra workload of screening and lack of financial coverage form obstacles for implementation.ConclusionsPulse palpation, automated blood pressure measure monitors with AF detection and single-lead ECGs might facilitate screening in a GP setting. When implementing screening, focus should lie on how to avoid disruption of consultation hours by unplanned 12-lead ECGs.

Atrial fibrillation: a geriatric perspective on the 2020 ESC guidelines

Background The Task Force for the diagnosis and management of atrial fibrillation (AF) of the European Society of Cardiology (ESC) published in 2020 the updated Guidelines for the Diagnosis and Management of Atrial Fibrillation with the contribution of the European Heart Rhythm Association (EHRA) of the ESC and the European Association for Cardiothoracic Surgery (EACTS). Methods and results In this narrative viewpoint, we approach AF from the perspective of aging medicine and try to provide the readers with information usually neglected in clinical routine, mainly due to the fact that while the large majority of AF patients in real life are older, frail and cognitively impaired, these are mostly excluded from clinical trials, and physicians’ attitudes often prevail over standardized algorithms. Conclusions On the basis of existing evidence, (1) opportunistic AF screening by pulse palpation or ECG rhythm strip is cost-effective, and (2) whereas advanced chronological age by itself is not a contraindication to AF treatment, a Comprehensive Geriatric Assessment (CGA) including frailty, cognitive impairment, falls and bleeding risk may assist in clinical decision making to provide the best individualized treatment.

Yield of two week holter monitoring and diagnostic accuracy of intermittent single-lead electrocardiogram recordings in screening for paroxysmal atrial fibrillation in primary care

Background Timely detection of atrial fibrillation (AF) is important because of its increased risk of thrombo-embolic events. Single time point screening interventions for AF are hindered because of AF's often paroxysmal nature. Community based prevalence of paroxysmal AF (pAF), however, is scarcely investigated. To detect pAF, often a Holter for prolonged electrocardiographic monitoring is used. Holter monitoring, however, is less appropriate for screening purposes because of its high burden for asymptomatic patients. Intermittent screening using a single-lead electrocardiogram (1L-ECG) device can offer a less burdensome alternative. Purpose To determine A) the diagnostic yield of two week Holter monitoring in screening for pAF after a negative 12-lead (12L-)ECG, B) the diagnostic accuracy of an intermittently used 1L-ECG device, and C) how often an expert panel is able to accurately diagnose AF by visually assessing the 1L-ECG recordings of patients with ≥1 algorithm-positive 1L-ECG recording(s). We used the Holter monitor as reference standard. Methods Patients of 65 years and older participated in an opportunistic screening study for AF. They received three screening tests (pulse palpation, electronic sphygmomanometer and a 1L-ECG device both with built-in AF detection algorithm). A 12L-ECG was recorded whenever at least one screening test was positive, supplemented with 10% of patients with three negative tests. We invited patients with a negative 12L-ECG to use a 1L-ECG device thrice daily and perform Holter monitoring for two weeks. We report the prevalence of pAF found by Holter monitoring and calculate the diagnostic accuracy of the 1L-ECG device's built-in AF detection algorithm. All 1L-ECG recordings of patients with ≥1 positive algorithm result were subsequently visually assessed by an expert panel of three cardiologists. Results We included 270 patients, of whom four had pAF on a median of 8.5 days of Holter monitoring: prevalence 1.5% (95%-CI: 0.4–3.8%). 205 patients were simultaneously screened with 1L-ECG recordings and Holter monitoring. Sensitivity was 67% (95%-CI: 9–99%), specificity 69% (95%-CI: 62–75%), positive predictive value 3% (95%-CI: 1–7%) and negative predictive value 99% (95%-CI: 97–100%) for diagnosing pAF based on the 1L-ECG device's built-in AF detection algorithm. Out of 65 patients with ≥1 algorithm-positive 1L-ECG recording(s), seven were classified as pAF after visual assessment by the expert panel. Six of these were false-positive. In 24 cases the expert panel could not interpret the 1L-ECGs. Conclusion We found a low prevalence of pAF using Holter monitoring in elderly primary care patients, with a negative 12L-ECG. The diagnostic accuracy of the built-in AF detection algorithm of an intermittently used 1L-ECG device is limited with a high false-positive rate. Cardiologists' assessment of algorithm-positive intermittent 1L-ECGs did not sufficiently improve accuracy to make a reliable diagnosis. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by ZonMw (The Netherlands Organisation for Health Research and Development)

Portable Interactive Pulse Tactile Recorder and Player System

Pulse palpation is an effective method for diagnosing arterial diseases. However, most pulse measurement devices use preconfigured pressures to collect pulse signals, and most pulse tactile simulators can only display standard or predefined pulse waveforms. Here, a portable interactive human pulse measurement and reproduction system was developed that allows users to take arbitrary pulses and experience realistic simulated pulse tactile feedback in real time by using their natural pulse-taking behaviors. The system includes a pulse tactile recorder and a pulse tactile player. Pulse palpation forces and vibrations can be recorded and realistically replayed for later tactile exploration and examination. To retain subtle but vital pulse information, empirical mode decomposition was used to decompose pulse waveforms into several intrinsic mode functions. Artificial neural networks were then trained based on intrinsic mode functions to determine the relationship between the driving signals of the pulse tactile player and the resulting vibration waveforms. Experimental results indicate that the average normalized root mean square error and the average R-squared values between the reproduced and original pulses were 0.0654 and 0.958 respectively, which indicate that the system can reproduce high-fidelity pulse tactile vibrations.

Prognostic impact of resting heart rate in patients with peripheral artery disease

Objectives Resting heart rate has been increasingly identified as a marker of cardiovascular risk and has been extensively studied as a predictor of coronary artery disease progression. In peripheral artery disease, the prognostic impact of resting heart rate remains elusive. Methods Consecutive patients undergoing invasive peripheral procedures were included. Data included resting heart rate determination by averaging manual radial pulse palpation measurements taken 24 h before and after an invasive peripheral procedure. Results A total of 1720 patients were included (mean age 70±11 years, 38% were female, 39% had critical limb ischemia). During a median follow-up of 729 days, 364 (21.2%) patients died. Resting heart rate emerged as an independent predictor of mortality, even after adjusting for clinical characteristics, peripheral artery disease manifestation and anatomic extent, traditional risk factors, co-morbidities, and disease-modifying therapies: hazard ratio for heart rate >75 bpm was 1.010 (95% confidence interval 1.001–1.109), with each bpm increase in resting heart rate conferring a 1.1% increase in the risk of all-cause mortality (95% confidence interval 0.1–10.9%, adjusted p = 0.030). Conclusions Resting heart rate is an independent predictor of mortality in patients with peripheral artery disease; our findings extend heart rate as a possible marker of prognosis to non-coronary atherosclerotic vascular disease.

Routine podiatry assessment as a potential preventive tool for atrial fibrillation screening in diabetics

Funding Acknowledgements Type of funding sources: None. Background/Introduction Atrial fibrillation (AF) is a common heart arrhythmia predominantly in advanced age patients and in diabetic’s type II (DMPII). Even if the risk of stroke in AF in DMPII is relative high, 25% of AF patients remains undiagnosed and also cryptogenic AF is very common in the diabetic population. During a 12-month study project, podiatrists and podologists performed foot pulse-checks in their routine podiatry assessment, when encountering visual symptoms that suggest an underlying circulatory disorder in diabetics. This simple non-invasive method aims to increase screening and diagnosis of AF from allied health professionals, in order to reveal patients with previously undiagnosed AF and patients with cryptogenic Af, challenging the potential reduction of AF complications and mainly of stroke. Purpose Early detection of AF in diabetics from allied health professionals during routine podiatry assessment. Revealing of previously undiagnosed AF contributes to stroke and other AF complications incidence reduction in the diabetics population. Methods During a 12-month study, 2 podiatrists and 6 podologists performed foot pulse-checks on diabetics, during their annual foot screening appointments, since they have been trained from medical doctors to spot rhythm abnormalities during pulse palpation of the foot arteries. They have been also trained to confirm their pulse palpation evidence thought Doppler ultrasound wave assessments during evaluation of arterial blood supply (anterior-posterior tibial arteries and ramifications) of the diabetic foot. During the study 300 diabetics (mean age 60 years old, 180 males, 120 females) had their feet pulse-tested. Spss statistical software had been used. Results 17% of diabetics during foot pulse-checks presents undiagnosed AF. There was no statistically significant difference (p < 0.05) between sex (males and females AF screening percents were similar). Conclusion(s) Early detection and properly managed during AF screening reduces AF complications and specifically stroke incidence. Opportunistic podiatric detection of previously undiagnosed and cryptogenic AF from allied professionals is a non invasive, safe, fast and economic method with potential contributions in this direction. More studies must be designed in order to support the routine podiatry assessment, as a useful Screening diagnostic tool of AF for reducing cardiovascular complications incidence in diabetics but also in the general population.

A Heart Rate Monitoring App (FibriCheck) for Atrial Fibrillation in General Practice: Pilot Usability Study

Background Atrial fibrillation (AF) is a major risk factor for stroke. The current opportunistic screening procedure consists of pulse palpation and an electrocardiogram when an irregular rhythm is found. Smartphone apps that measure heart rhythm could be useful in increasing the detection of AF in a primary care setting. Objective We conducted a pilot study with the smartphone app FibriCheck to assess whether the introduction of such an app is feasible. Methods Four general practices across Flanders provided patient data for the study. Inclusion criteria for participants were aged 65 or older and a CHARGE-AF score of at least 10%. We excluded patients with known AF or a pacemaker. Participants were asked to measure at least twice a day with FibriCheck (for at least 14 days). They were provided the 36-Item Short Form Survey (SF-36) questionnaire both before and after the study, as well as different surveys concerning their user experience and general perception of technology. Results There were 92 participants (36 women and 56 men). The study population was relatively homogenous concerning risk factors and medication use at baseline. During the study period, 5/86 (6%) participants were found to have AF (6 dropouts). The average study period was 23 days and the average number of measurements per day was 2.1. Patient compliance was variable, but high. On the whole, there were no appreciable changes in quality of life. The overall user experience and satisfaction were very high. Conclusions FibriCheck is a relatively easy-to-use smartphone app to complement AF screening in primary care. Its implementation in this setting is certainly achievable, and one can expect high rates of patient compliance. Based on these results, a planned cluster randomized trial will be going ahead. Trial Registration ClinicalTrials.gov NCT03509493; https://clinicaltrials.gov/ct2/show/NCT03509493