The Role of Primary Care Pharmacists in the Detection of Atrial Fibrillation

Atrial fibrillation (AF) affects up to 10% of ≥ 65-year-olds and contributes to one in four ischaemic strokes, costing the UK economy > £1 billion each year. Clinical pharmacists' (CPs) integration into general practitioner (GP) surgeries and care homes offers an opportunity to facilitate AF screening. This thesis aimed to explore the role of primary care CPs in AF screening excluding the community pharmacy environment.

The 'Pharmacists Detecting Atrial Fibrillation' (PDAF) study recruited 604 participants aged ≥ 65 years in GP surgeries over two influenza vaccination seasons. CP-led AF screening, using pulse palpation and single-lead electrocardiogram (SLECG) devices, identified 'new' AF in 1.3% of individuals who qualified for oral anticoagulant (OAC) therapy. This intervention had a 72% probability of being cost-effective, particularly with SLECG devices rather than pulse palpation which produced 5.2% more false positive AF diagnoses. Patients, CPs and practice staff praised the convenience of screening and emphasised the role of CPs in reassuring patients. Their vision of AF screening involved a personalised cardiovascular disease (CVD) service targeting at-risk groups. The PDAF study therefore extended into care homes. A further 53 participants were recruited, and 9.6% were found to have undiagnosed AF qualifying for OAC therapy. Screening using SLECG devices in this setting was 89% cost-effective but suffered from under-recruitment, low follow-up rates and poor diagnostic accuracy.

Another initiative used SLECG devices to deliver AF screening within a South Asian community setting. Pharmacy undergraduates of matching heritage screened 572 participants over nine days under CP supervision. Out of ≥ 65s, 1.5% had a newly detected AF and could be considered for OAC therapy. The intervention had a 95% probability of being cost-effective and was viewed as a valuable cause for local community, although its future implementation could be compromised by ineffective referrals to GP surgeries.

Semi-structured interviews with 10 GPs showed that clinicians were overall in favour of structured AF screening programmes targeting ≥ 65s or those at-risk of AF/stroke. Sustainable, widespread AF screening in GP surgeries could be achieved by obtaining further clinical evidence and additional support from the Government and utilising local champions. Pharmacist-led AF screening was viewed as an option, yet nurses or healthcare assistants were preferred due to their intrinsic clinical skillset.

This enquiry demonstrates that CPs can facilitate effective, cost-effective and well-accepted AF screening in GP surgeries, care homes and community settings. Future research should explore the feasibility of integrating such pharmacist-led AF screening programmes within CVD care packages and should investigate their impact on clinical endpoints.