# The pathway to diagnosis and follow-up care for atrial fibrillation in Sri Lanka: a descriptive longitudinal study

## TL;DR

This study examines how atrial fibrillation is diagnosed and managed in Sri Lanka, revealing late diagnoses and pandemic-related disruptions in care.

## Contribution

The study provides novel insights into AF care pathways in a low-resource setting during the COVID-19 pandemic.

## Key findings

- Most AF diagnoses in Sri Lanka occur in emergency or inpatient settings, not primary care.
- The pandemic disrupted AF care, causing fewer healthcare visits and delayed medication access.
- Strengthening primary care could improve early AF diagnosis and continuity of treatment.

## Abstract

Early diagnosis and continuity of care is vital for atrial fibrillation (AF), a major risk factor for stroke that requires regular monitoring when treated with warfarin; however, evidence on AF care in LMICs is lacking. We aimed to identify the AF patient pathway in Northern Province, Sri Lanka and to determine how the COVID-19 pandemic impacted AF care.

This descriptive longitudinal study utilised two questionnaires, which were previously used in India and Mongolia to quantitatively evaluate the AF pathway: one at baseline and one ≥3 months following baseline. Adults (≥18 years) with AF were recruited from the A&E department and outpatient clinics located at the Jaffna Teaching Hospital, the only tertiary hospital with cardiologists and 12-lead echocardiogram facilities in the Province. Data were collected between October 2020 and June 2021 and analysed using descriptive statistics.

This study included 151 participants (median age 57 years, IQR 49-67; 70% female). Most participants were diagnosed in the A&E (38%) or inpatient department (26%), followed by an outpatient department (19%) or private facility (16%). Nearly all (97%) participants received follow-up care during the study period, with an average of 1.3 AF-related healthcare visits per person; most visited an outpatient department (88%). The COVID-19 pandemic negatively impacted 39% of participants’ care: fewer healthcare visits, delayed or unattainable medications, and longer intervals between blood tests; however, 24% of participants received their medication by ambulance, public health staff or post.

Primary care was not involved in the diagnosis of AF, leading to most diagnoses occurring after a medical emergency. The frequency of blood tests was lower than guideline recommendations and could in-part be due to the adverse impacts of the pandemic. Strengthening primary and community-based care may enable early diagnosis and improve continuity of care during and beyond future healthcare crises/emergencies.

Atrial fibrillation (AF) is a condition that affects the heart rhythm and increases the risk of stroke. AF can be treated by anticoagulant drugs, which thin the blood and prevent blood clots. Warfarin, the most common anticoagulant drug prescribed for AF in low- and middle-income countries (LMICs), is effective in controlling the heart rhythm and can reduce strokes. However, the dose of warfarin must be monitored monthly (typically by a blood test called international normalised ratio (INR)) and often changed to ensure patient safety. It is important for AF to be diagnosed early within primary care for people to receive life-saving medication to effectively manage AF and prevent stroke.

Sri Lanka, a LMIC in Southeast Asia, has limited healthcare resources and poor awareness of AF. Like most countries around the world, the coronavirus disease (COVID-19) pandemic impacted healthcare in Sri Lanka with travel restrictions and lockdowns; AF care was likely impacted but, to the best of our knowledge, no study has investigated how. Therefore, we administered a questionnaire to people with AF receiving care from the only teaching hospital in Northern Province Sri Lanka that has a specialised clinic for AF aimed at understanding where people with AF get diagnosed, where they receive follow-up care and how the COVID-19 pandemic impacted their care.

None of the 151 participants were diagnosed in primary care. Most participants were diagnosed in emergency or inpatients departments, indicating that AF was recognised after a major health problem such as stroke. The frequency of follow-up visits during the study period to receive an INR test was lower than guideline recommendations and the COVID-19 pandemic negatively impacted the availability and accessibility of warfarin and INR tests.

This study suggests that primary care must be strengthened to enable early diagnosis and improve continuity of care, especially during healthcare crises like a pandemic.