Health & Science blog

And so, to my mail box this morning.

“Dear Doctor

We are writing to brief you about the British Heart Foundation’s forthcoming Atrial Fibrillation campaign [when the upper chambers of the heart beat in an unco-ordinated fashion].

The campaign aims to increase people’s awareness of asymptomatic AF and encourages them to check their pulse for an irregular rhythm…The campaign will be starting on 16th November 2009 and will run across the following weeks. We will be directing people to visit our website or call a bespoke telephone line which will provide information about AF, how to check their pulse, and the difference between a regular and an irregular pulse…We would value your assistance in communicating the above information with your own patients, colleagues and networks.”

The picture at the top of the BHF website is of someone checking his pulse and the ominous message “An irregular pulse can kill. Don’t leave it to chance.”

So, a nice little campaign that should see us clutching our wrists, taking our pulse, and saving our lives?

Well, be in no doubts: this is a screening campaign. This wants people who are feeling well to perform a self-check: and although they have the option of asking a nurse on the phone what to do, if in any doubt, they are to seek advice from their GP. Which is what you will have to do if you think there could be an abnormality anyway.

Now if someone has heart symptoms, they are symptomatic, and there is no doubt they should get medical advice. But this is different – it’s screening. Screening programmes should not just be thought up and let loose.

They have the potential to do harm, even when they are “working”. These programmes take time, money, and energy and should be justified, especially as it may mean resources are diverted from somewhere else.

And can we justify screening for atrial fibrillation? This is a question which has been asked very seriously over the past decade or so. First, though – no studies that I can find have examined effectiveness and harms done by encouraging people to check their pulse as the BHF do. And there has been no estimation of the false alarms, and wasted time and energy that could be caused.

A study in 2007 published in the BMJ suggested that a healthcare professional taking a pulse was useful at picking up cases of AF.

However this has to be then followed by confirmation of the diagnosis and treatment. Treatment of AF involves drugs to control the speed the heart beats at and also to thin the blood. Not everyone can take these types of medication – some people have conditions that interacting – and other people will have side effects, namely bleeding.

The hope is that with a condition like AF, you offer treatment which has more chance of doing good than harm – but of course this is a decision that has to be made. It’s not as easy as, say, just checking your pulse.

And why isn’t such a system for screening for AF up and running in the UK? Check out the NHS Screening Portal and the current policy, based on a Health Technology Assessment and last reviewed earlier this year, state that “screening should not be offered.”

Essentially, they were unconvinced that this was an efficient way of picking up treatable problems. This balance might change in the future. If it did, people would need information about the pros and cons of treatment, and a screening programme would have to be properly organised and resourced.

The problem is also that general practice is a wee bit stretched at the moment, what with H1N1 and all that, and I don’t think now is quite the right time to be launching an untested screening programme on the public.  (And another interesting point about the BHF can be found here, in their press release:  ”only a quarter of people (28%) knew taking their pulse is a health check people should carry out on themselves, in contrast with a high awareness of breast cancer (89%) or testicular cancer (90%) checks.” This sounds to me like awareness envy, not delivery of fair evidence based medicine.