Introduction

A pulse check followed by a confirmatory 12-lead ECG is the accepted standard screening test for detecting atrial fibrillation in the over 65 years age group.

A pilot of 34,201 patients in North East Essex flu clinics yielded: 3154 patients (9.2%) with an irregular pulse 189 patients (0.55%) with unknown atrial fibrillation

Dr. Matt Fay (National Clinical Lead, Stroke NHS Improvement Program) set the challenge of designing a rapid test that could be undertaken in less than 3 minutes whilst having better sensitivity and specificity than a pulse check.

In response to the challenge, Technomed developed their ECG CLOUD Cardiac Rhythm Test.

The ECG CLOUD System allowed a simple limb-lead ECG to be recorded within an appointment slot of 3 minutes. The ECG’s were transmitted to a remote cardiology expert and reported via a web browser interface. The results were returned on a next working day basis.

The equipment is easy to use and can be operated by healthcare assistants with the minimum of training. Barcode data entry and a simplified electrode arrangement enabled 20 patients per hour to be processed per workstation.

Process

  1. Print Cardiac Rhythm Test Request Form from patient electronic record (patient demographics & ID encoded into 2D Barcode).
  2. Welcome patient and sit him/her down
  3. Attach limb-lead electrodes
  4. Enter patient demographics using barcode scanner
  5. Acquire ECG (10 seconds)
  6. Digitally Transmit ECG (
  7. Remove electrodes and exit patient
  8. ECG analysed remotely by cardiac physiologist under consultant supervision
  9. Reports returned to practice with those patients with positive results highlighted
  10. Positive results triaged via arrhythmia nurse (optional)

STEPS 2 – 7 undertaken in less than 3 minutes

Summary Results (patients of 65 years of age and over)

 Number%
Total Patients Enrolled 6150 100.00
Patients in atrial fibrillation (AF) 252 4.09
Patients with previously undetected AF 65 1.06
Patients in atrial flutter 16 0.27
Patients in complete heart block 3 0.05
Patient with a ventricular rate less than 41 bpm 5 0.08
Patients with a ventricular rate less than 51 bpm 120 1.95
Patients with a ventricular rate less than 60 bpm 750 12.18
Patients with a PR interval greater than 209 ms 441 7.16
Patients with a PR interval greater than 249 ms 80 1.30
Patients with a QRS interval greater than 119 ms 568 9.22
Patients with a QRS interval greater than 149 ms 178 2.89
Patients with ventricular ectopics 522 8.48
Patients with an ECG quality too poor to interpret 20 0.33

Conclusion

The results of the Bradford ECG Cloud Pilot compared favorably with the yields obtained in North East Essex.  Previously undiagnosed atrial fibrillation was detected in 1.06% of patients vs. 0.55%. The difference may reflect a higher incidence of undiagnosed AF in Bradford. Alternatively 6 lead ECG may have better sensitivity for identifying AF compared with pulse palpation followed by 12 lead ECG, possibly days later. Certainly specificity is far higher. Although manual pulse palpation is slightly faster than the ECG Cloud Rhythm Test it has a false positive rate of 94%.

Pilot Supervisors

Dr. Matt Fay, National Clinical Lead, Stroke, NHS Improvement Program

Dr. Steven Lindsay, Consultant Cardiologist & Clinical Director at Bradford Hospitals NHS Trust.

I hereby certify that the above information is true and correct to the best of my knowledge.

Date:28/11/2011

Dr. Matt Fay,National Clinical Lead, NHS Improvement and GP

I hereby certify that the above information is true and correct to the best of my knowledge.

Date:28/11/2011

Dr. Steve Lindsay,Consultant Cardiologist, Bradford Royal Infirmary

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