Dr. William Paiva, Ph.D.
Dr. Kathryn Farguson, D.O.
Dr. D. Matthew Wilkett, D.O.
Dr. Patrick Henderson, D.O.

Rural Oklahoma health care physicians who provide primary care enrolled patients who volunteered and qualified into a free study that might reduce their risk of stroke. A total of 236 rural patients were screened.  Additionally, ninety-one charts of patients in rural Oklahoma with atrial fibrillation were reviewed for rural treatment implications.

CHSI focused on rural atrial fibrillation because a growing problem in healthcare is the clinical and financial impact of asymptomatic atrial fibrillation because it is most regularly found after stroke. Atrial fibrillation alone accounts for a large percentage of referrals to OSU Cardiology, and very little is known about the incidence of asymptomatic Atrial Fibrillation.

Other studies have shown that rural populations are at significantly higher risk of atrial fibrillation and stroke due to their increased cardiovascular risk factors. Moreover, treating rural patients has added complications such as patients often having fewer resources. In addition to our questions about incidence of undetected atrial fibrillation, we also want to understand if and how the treatment of atrial fibrillation reflects rural health obstacles.

CHSI’s overall goal is to help rural physicians. In this study, learning about rural incidence and treatment of atrial fibrillation, in our opinion, is groundbreaking. 

• To determine the incidence of silent, or asymptomatic, atrial fibrillation (AF) of patients 65 years of age and older in rural (nonmetropolitan counties with population less than 20,000) and non-metropolitan (nonmetropolitan counties with population 20,000 – 50,000) healthcare centers of Oklahoma.
• To determine current management strategies for rural asymptomatic AF patients specific to the targeted patients 65 and older meeting inclusion criteria.
• To determine how protocols for treatment of rural atrial fibrillation patients take into account and reflect issues such as few resources and potentially long travel times that rural patients may struggle with, whether protocols have been altered in these healthcare centers to account for these potential issues, and in what ways they have been changed.

• Stroke Prevention. Atrial Fibrillation is the most common clinical arrhythmia with the prevalence increasing with age. It is estimated that 6-8% of the population over 75 have AF. Atrial fibrillation is also an increasing risk factor for stroke, with AF being present in 25 – 30% of patients who have had an acute ischemic stroke. Atrial fibrillation presenting without symptoms is referred to as silent atrial fibrillation, with rates of up to 30% of those with AF. Those with silent AF are often not diagnosed until after they have experienced a stroke, and early detection and treatment of atrial fibrillation with oral anticoagulants reduces strokes by 64%, making early detection of silent AF extremely important.
• Rural Healthcare. Rural populations are being specifically targeted due to the high prevalence of cardiac risk factors such as obesity, hypertension, diabetes, and tobacco use that contribute to development of cardiovascular disease such as AF and increased risk of stroke within rural populations. In addition, little is known about the status of atrial fibrillation in this population, and much benefit can be gained to both physicians and the population by better understanding the scope of the problem.

• Inclusion criteria:                                                                        
  • Patients : 65 years                                                    
• Exclusion criteria:
  • Patients with diagnosed Atrial Fibrillation
  • Patients previously diagnosed with arrhythmia(s) other than Atrial Fibrillation
  • Patients with a cardiac pacemaker, ICD or other implanted electronic device.
  • Patients taking anti-arrhythmic drugs for any reason, including: Sotalol, Amiodarone, Dronedarone, Dofetalide, Procainamide, Flecainide, Quinidine, Mexiletine.
  • Non-English speaking patients
  • Non-literate patients

• The AliveCor Heart Monitor (Heart Monitor) is a mobile, FDA approved clinical-quality electrocardiogram (ECG) recorder (see section on AliveCor® for detailed information and tutorial). Learn more about AliveCor at www.alivecor.com. Rural populations meeting inclusion criteria were targeted by screening for AF in healthcare clinics in rural areas around the state of Oklahoma using AliveCor iECG screening devices which utilizes the approved FDA AliveCor® screening algorithm.
• If AliveCor® Detects AF Then 12 Lead ECG Confirmation. If Atrial Fibrillation or other arrhythmia is detected with the AliveCor® device, the physician will be asked to confirm any known AF history or symptoms. A confirmatory 12-lead ECG will be conducted by the participating attending. The EKG will be faxed to the cardiologists and primary investigators for free and timely EKG reading to confirm AF diagnosis and/or any other diagnosis from EKG reading. This report will be provided back to the clinic.
• Medical Chart Reviews of Patients with AFib. In addition to screening for silent Atrial Fibrillation in selected rural clinics, patient charts of persons with diagnosed Atrial Fibrillation in a rural clinic without a cardiologist were reviewed through a standardized medical records review. Information tracked included medications pertinent to the treatment of Atrial Fibrillation, referrals to cardiac specialists, pharmacy fill rates and appointment compliance, as well as criteria for determining CHA2DS2-VASc score.  The patient’s age, gender, and presence or history of Congestive Heart Failure, Hypertension, Diabetes Mellitus, Vascular Disease, and prior Stroke, Transient Ischemic Attack, or Thromboembolism. For purposes of this study, patients will be filtered by their CHA2DS2-VASc score to determine if the recommended interventions were followed, and the effects of these interventions after a period of one year.

• The study sought to screen 200 patients and chart review 50 patients.  Enrollment exceeded goal with 236 patients screened and 91 patient charts reviewed.

The study completed enrollment and chart reviews October 2016. The study data is currently under review and being analyzed.