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AF Screening Best Practices
Screening and Shared Decision-Making Best Practices for Patients With Atrial Fibrillation

Released: January 23, 2024

Camille Dyer
Camille Dyer, MS, PA-C, AACC, DFAAPA
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Key Takeaways
  • In screening patients for atrial fibrillation, it is critical to get a complete understanding of their past medical history and CHA2DS2-VASc score.
  • Asking open-ended questions is a key component to obtaining an accurate medical history to assess atrial fibrillation risk.

Screening for Atrial Fibrillation (AF) Risk Factors
Common risk factors for the development of AF include many of the comorbidities that are seen in primary care day in and day out: obesity, diabetes, cardiovascular disease, chronic kidney disease, heart failure, hypertension, obstructive sleep apnea, valvular heart disease, etc. Each of these contributes to an individual’s risk of developing AF, and ultimately, experiencing a stroke from AF. Careful assessment of risk factors that may lead to the development of AF is critical, as this can help identify individuals who should be screened. AF is the most common cardiac arrhythmia globally, and a large percentage of individuals are undiagnosed due to lack of symptoms. As healthcare professionals (HCPs), we must recognize the constellation of risk factors to accurately screen and diagnose AF, particularly as many of these comorbidities occur in underserved patient populations who may have limited or decreased access to healthcare.

Once an individual develops AF, many of these same disease states contribute to the assessment of their overall stroke risk through the calculation of their CHA2DS2-VASc score. Sex, age, a history of heart failure, hypertension, diabetes, stroke, and vascular disease all increase an individual’s annual risk of experiencing a stroke. An important point to remember is when heart failure is referenced, it includes both reduced and preserved ejection fraction. With hypertension, it is critical to acknowledge individuals are at an increased risk even if they are on treatment and their blood pressure is at goal. Careful assessment of an individual’s CHA2DS2-VASc score will help determine the need for anticoagulation, so it is important to assess each risk correctly.

Health Disparities and Screening for AF
Screening for AF is critical to optimizing patient outcomes, and modern research shows that many historically marginalized and underrepresented patients present with several risk factors associated with AF. Yet these groups are less likely to be diagnosed with AF than their White counterparts. Studies are assessing why these discrepancies exist because, on the surface, it is paradoxical. In terms of social determinants of health that impact these patients, various factors play into their presentation. There are financial considerations, commonly referred to as economic stability. Health literacy also plays a role, expanding into the educational space. Consideration of the social and community context is also important and refers to their social support system. Trying to understand who will be there to support the patient in managing their health care is essential. Therefore, when addressing health disparities for patients with AF, HCPs must assess these factors to better understand how they impact their patients, adjusting their practice to accommodate for any barriers that may be in place.

Unfortunately, in practice, addressing health disparities is more complicated than implementing simple adjustments. Most AF diagnoses are made based on the patient’s past medical history. Without an accurate history, it is impossible to fully assess a patient’s risk factors for developing AF. It is so important for HCPs to effectively engage and interact with their patients. Not being able to do so—for various reasons such as language barriers, cultural barriers, or simply avoidance of care due to medical mistrust—may contribute to some of the discrepancies and disparities. It is anticipated that ongoing research will provide more data on the specific disparities that impact particular patient populations. In the interim, it is important to know how to discuss patients’ medical history with them, paying particular attention to the manner in which questions are asked. Ensuring questions are open-ended and asked at an appropriate education level can enhance the assessment of a patient’s past medical history.

When evaluating health disparities, it also matters who is asking the questions and documenting the history. If patients see an HCP that looks like them and has similar cultural values, they may be more willing to share what is happening with their health. In addition, some questions need to be more pointed. For example, HCPs should not simply ask, “Do you have a cardiac history?” Depending on the population being seen and available resources in your area, you may have to ask more specific questions; ask about patients’ sugar intake instead of a history of diabetes or high blood pressure rather than hypertension. Where we can implement change as HCPs is being more cognizant of how questions are asked and having discussions with patients. Using layman’s terms to take a history and discuss risk factors for AF can really help individuals understand how their comorbidities can contribute to developing AF and impacting their long-term health.

Of note, when asked a complex question, which happens periodically, and if I do not know the answer, I will openly admit that I am unsure of the answer. This helps build trust and honesty. I will then investigate the issue and find an answer for them, ensuring that appropriate follow-up is provided. This too helps build trust and confidence.

Tips for Engaging Patients in Their Care
One area worth exploring in clinical practice is bringing patients in for a screening appointment with an emphasis on having these conversations. This approach will allow a more focused discussion since there are always so many concerns to address, from the AF itself to the screening to be performed to assess the risks associated with stroke. However, balancing this with any transportation, financial, or childcare issues that can complicate a patients’ care is imperative.

How I discuss stroke risk with patients has evolved based on my experience; it is not something I learned in the classroom. I share with individuals that it can be “nothing” or a life-altering stroke, and there is no way to predict which will occur. In discussing AF, my approach is similar. If someone has paroxysmal AF, there is no way to predict when it will come back or how often. As taught in school, “AF begets AF.” It will be back and unfortunately, the currently available knowledge and technology does not allow the prediction of when it will happen again. AF is a chronic disease. Patients may come in for an ECG as part of their routine physical and present with AF, yet it may be gone at their follow-up visit. Therefore, having dedicated time to explain and ensure patients understand that this could be the natural course of AF as well as understanding their risks regarding AF is critical.

In the primary care setting, these are difficult conversations to have because it is complicated and nuanced, considering this is the same setting where HCPs are addressing patients’ other concerns, such as stomach pain, back pain, and various other chronic conditions that can impede the patient’s ability to process all of the information being addressed. Further, patients can only take in so much information at a time.

For individuals in rural settings, some patients need to drive an hour or more to see an HCP. Breaking up their visit throughout the day is one strategy to help address these concerns and avoid having patients travel significant distances repeatedly. One option could be to see patients for issue number one, have them take a break to eat and/or relax, and come back for a second visit to discuss other issues or concerns. Giving patients time to process the information makes utilizing shared decision-making more of a reality and allows patients the space to take knowledge in and make decisions in which they can be confident.

With AF screening, HCPs often practice pulse checks and teach patients how to do these checks by themselves. However, if an individual has a high level of anxiety, they may not be the right patient for this practice, but perhaps a family member can assist them. Again, it comes back to having that patient–provider relationship and detailed conversations to truly understand a patient’s resources and their personality, which impacts their ability to process the information being shared and implement treatment strategies recommended. These tips for patient care are what will help HCPs ensure our patients can and will participate in the shared decision-making process.

Technology’s Role in and Outside Your Office
There are a lot of apps that are available via smartphones or smartwatches that patients with AF can use to monitor their health. HCPs can in fact “prescribe” these to their patients. Most apps and devices will help assess patients’ vitals over time, and the data taken can be sent directly to the HCP. With this, all HCPs should set patient expectations accordingly. If you are not going to bring them in for an appointment, make sure you are providing reasonable expectations and a time frame in which they will hear back from you. It is important not to leave patients in limbo, as it can result in some calling office staff throughout the day because they are anxious about the interpretation of their results. Managing patient expectations is vital to a healthy patient–provider relationship.

Determining which app or smart device is best for patients will depend on the frequency of their symptoms. Most are great for patients who have relatively frequent symptoms, but for those with periodic symptoms, you may want to investigate an event monitor or insertable loop recorder. The take-home message here is that it is critical to probe patients to ensure a clear understanding of their symptoms and the frequency with which they are occurring to inform the decision on which screening/monitoring tool is best for the patient.

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