Current practice of Dutch cardiologists in detecting and diagnosing atrial fibrillation: results of an online case vignette study

Abstract

Introduction: Detection of atrial fibrillation (AF) is important given the risk of complications, such as stroke and heart failure, and the need for preventive measures. Detection is complicated because AF can be silent or paroxysmal. Describing current practice may give clues to improve AF detection. The aim of this study was to describe how cardiologists currently detect AF.

Methods: Between December 2014 and May 2015, we sent Dutch cardiologists an online questionnaire. Firstly, we asked which tools for detection of AF their department has. Secondly, we presented six case vignettes related to AF, in which they could choose a diagnostic tool. Thirdly, we compared the results with current guidelines.

Results: We approached 90 cardiology departments and 48 (53%) completed the questionnaire. In asymptomatic patients with risk factors according to CHA₂DS₂-VASc, 40% of the cardiologists would screen for AF. In patients with signs or symptoms of AF, all but one cardiologist would start a diagnostic process. In both vignettes describing patients with non-frequent symptoms, 46% and 54% of the responders would use short-term (i. e. 24- or 48-hour) electrocardiographic monitoring, 48% and 27% would use long-term (i. e. 7 day, 14 day or one month) monitoring. In both cases describing patients with frequent symptoms, 85% of the responders would use short-term and 15% and 4% long-term monitoring.

Conclusion: Dutch cardiologists have access to a wide variety of ambulatory arrhythmia monitoring tools. Nearly half of the cardiologists would perform opportunistic screening. In cases with non-frequent symptoms, monitoring duration was shorter than recommended by NICE.

Keywords: Ambulatory electrocardiography; Atrial fibrillation; Electrocardiography; Health care surveys; Paroxysmal tachycardia; Practice guideline.

Fig. 1

Geographic distribution of responding (n = 48, black) and non-responding cardiology departments (n = 42, grey)

Fig. 2

Techniques for ECG registration available at the responding cardiology departments (n = 48). (* This category consisted of the NUUBO (wireless ECG recording) and teaching patients to feel their own pulse)

Fig. 3

The initially applied diagnostic technique for each case vignette* (n = 48 cardiology departments). (* See Table 1 for case vignette descriptions)

Fig. 4

The subsequent diagnostic actions for each case vignette* in which a 12-lead ECG was chosen as the initial diagnostic test but did not reveal atrial fibrillation (n = 48 cardiology departments). (* See Table 1 for case vignette descriptions)