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AF Burden
The Burden of Undiagnosed Atrial Fibrillation

Released: January 19, 2024

David S. Kountz
David S. Kountz, MD, MBA, MACP
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Key Takeaways
  • In my personal experience, patients are often extremely concerned about experiencing a stroke.
  • Integrating atrial fibrillation screening into the primary care setting is imperative and should be part of every clinician’s checklist for each appointment. 

The Patient Burden of Undiagnosed Atrial Fibrillation (AF)

When you read surveys of what people fear as they get older, having a stroke, becoming incapacitated, and being a burden to their family is one of their greatest concerns. It’s a profound fear that our patients have, and people would rather have a heart attack than have a stroke. In my conversations with patients discussing the importance of blood pressure and glycemic control in the context of the added benefit of reducing their risk of stroke, they are much more engaged. There's probably nothing that engages them more. Therefore, because we know the risk of stroke is so much greater in patients with undiagnosed AF, it is not only paramount that we screen frequently, but that we share this information with our patients. I find that they are very focused on “What can I do to reduce my risk”?

This insight is a real opportunity for us as clinicians to understand how our patients feel about the potential of a stroke. It also offers a deeper understanding of how they may feel about AF. If an individual’s greatest fear is having a stroke, and we know that AF carries a much greater likelihood of stroke, it behooves us to screen them regularly. Screening for AF in the elderly is so important. Listening carefully for signs or symptoms and periodically doing ECGs to look for evidence of an irregular heart rhythm can hopefully avoid a debilitating stroke in our geriatric patients.

The other thing that we're starting to see that's changing, more so with younger and middle-aged individuals, is the advent of wearable technology. More and more we're seeing patients or family members of patients calling in the office and saying, "Hey, we got dad a particular type of watch and set it for his heart rhythm. We noticed it's irregular." There's more patient empowerment. It’s an interesting trend that we have not seen in previous years, and it is something that can potentially help individuals avoid a stroke from AF.

Assessing Patient Risk Factors for AF

Traditional risk factors such as hypertension, particularly if it's long-standing and/or untreated, remain major risk factors. We know that so many elderly patients develop hypertension, particularly systolic hypertension. In addition, as the heart enlarges, largely from hypertension, left ventricular hypertrophy can also increase the risk of AF. Other chronic conditions, such as diabetes and hyperlipidemia put patients at increased risk. However, probably the most important risk factor is simply aging. A patient may not have obvious treatable risk factors, but as they reach the sixth or seventh decade of life, that in itself increases the risk of AF. So, we shouldn't just say, "Well, this patient doesn't have hypertension," and elect not to think about screening. We need to screen all our elderly patients for this likelihood.

We all know that AF can be asymptomatic. When it comes to screening, we tend to think about patients who come in and complain about palpitations, but plenty of individuals may not have a single complaint. So, it's incumbent upon us to be active in screening. Simply asking a question about palpitations is not sufficient. One of the challenges of screening is that with paroxysmal AF, a patient may come into clinic in normal sinus rhythm, and the minute they walk out of the office, they've flipped into AF. So, I think we all have to be kind to ourselves. We are going to do the best we can from a screening standpoint, but this doesn’t mean that it is not important to screen at every chance you get.

Implementing Screening for AF in Primary Care

It is very difficult to fit so many things into a short appointment. That is the harsh reality of the busy, and frankly, overwhelmed primary care clinician. Individuals have other chronic conditions that need to be addressed. As clinicians we are trying to address the patients’ concerns, figure out how to get patients medications or services in the community, on and on. So, I think AF screening just has to be a high priority. While it may seem that palpitations are a consistent finding with AF, approximately 30% of patients are asymptomatic, so formal screening is critical. It's almost as if you were treating a patient with diabetes; you know you have to take their shoes off. Someone during the appointment—your medical assistant, your nurse, you—have to look at their feet at every visit. The same sort of system needs to be implemented for AF screening. Screening for AF must be a careful, 30-second to 1-minute exam that is part of every visit. I do think the idea of—particularly if a family member is present—teaching them about how to periodically monitor the regularity of their pulse rate at the wrist and be willing to accept some phone calls and maybe even some unnecessary visits, just to try to get ahead of things. It has to be part of the routine and built into our practice and culture.

Using Pulse Palpation as a Screening Tool

When it comes to home pulse palpation, I try to be consistent. I do appreciate, frankly, that some patients will be more motivated and focused than others, but I don't always know that I can accurately predict that. So, to avoid bias, I like to recommend home pulse palpation to every patient. I think it's especially effective if family is part of the conversation. Often the patient is so overwhelmed with all the information presented to them at each visit. Family members can help facilitate knowledge that may not have struck home with the patient the first time around.

There have been times when I've shown patients’ families how to check the pulse at the wrist. When a patient comes by themselves, I see if I or someone from my team can call a family member with the patient's consent and say, "Here are the things we talked about with your dad today, and one of the things we talked about was monitoring pulse"—conveying that this is something that they can do at home for their family member. It is always best in person, but if they are unable to come in, at least we have had a phone conversation to provide each patient with the best care possible. Of course, you assess the presence of symptoms carefully regardless of whether an individual or family member can complete screening at home. Sometimes home screening is not feasible, and the best we can do is screen in the office and hope an individual is not having intervals of AF between visits.

Discussing AF and Stroke Risk With Patients

I think that there is some general population awareness of stroke, but there is not as much awareness of what AF is, so that's an important conversation to have with patients and family members. When I discuss it with my patients, I try to convey a small amount of information about what it means if your pulse is irregular. It can become complicated for patients when you talk about blood pooling in the heart. I think we must realize that patients can lose focus or get very anxious when we go into too much detail. It is a difficult conversation to have. I try to keep it simple and say that having a regular pulse is important. If it's irregular, I tell them that they need to come back and see me as soon as they can, and then we can talk about what that irregular pulse might mean and treatment options.

It's still part of our role in the primary care setting to try to do some degree of teaching. It is important to make sure that individuals are aware that if their pulse is irregular or they have symptoms of palpitations, lightheadedness, etc, that they need to come in and see their primary care clinician or go to the emergency department. Making sure they understand that it is an important part of their health.

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