Authors: (including presenting author): :
Lai KPL(1), Chan PF(1), Fung HT(1), Wong SN (1), Luk MHM (1), Chan WY (1), Leung CY (2), Wong CH (2), Ching S (3), Mak K (4), Mak CK (4), Chan M (4)
Affiliation: :
(1)Department of Family Medicine and Primary Health Care, Kowloon East Cluster (KEC) (2)Department of Medicine, Tseung Kwan O Hospital (TKOH)
(3)Department of Medicine & Geriatrics, United Christian Hospital (UCH)
(4)Department of Pharmacy, KEC
Keyword 1: :
Atrial fibrillation
Keyword 2: :
Primary Care
Keyword 4: :
Non-vitamin K oral anticoagulants
Keyword 5: :
Echocardiography
Keyword 6: :
Pharmacist Clinic
Introduction: :
Atrial fibrillation (AF) is one of the most commonly encountered heart conditions that has significant clinical impact in both primary and secondary care settings. Patients with AF are at a higher risk of hospitalization and complications such as heart failure and various thromboembolic events. Family physicians play a crucial role in providing comprehensive management for patients with AF. With an aging population, it is expected to double the prevalence of AF in the next few decades. There is a pressing need to enhance our service capacity. In response, KEC Family Medicine Clinics (FMCs) have adopted a multifaceted and multidisciplinary approach that includes early detection using technology, thorough assessment, and comprehensive management strategies. These initiatives reflect a commitment to improving the quality of care for AF patients within primary care setting.
Objectives: :
To provide comprehensive and multidisciplinary clinical management for patients with AF in primary care.
Methodology: :
AF clinics were established at KEC FMCs in 2019, with the introduction of non-vitamin K oral anticoagulants (NOACs). Updated clinical guidelines were developed to guide the pharmacological treatment of AF and its complications. An automated blood pressure device with an AF detection function was introduced for diabetic patients undergoing diabetes complication screening starting in 2021. Transthoracic echocardiography (TTE) services performed by FM consultants were implemented in 2023, along with specialist consultative support by cardiologists from parent hospitals. A Pharmacist Clinic was established in July 2025 to provide medication counselling for patients newly started on NOACs or those with potential drug-drug interactions.
Result & Outcome: :
The service statistics for 2025 were reviewed. A total of 2,946 AF patients were seen in KEC FMCs in 2025. This represents a 7.4% increase in the total number of patients with AF compared to 2024 (2,744 in 2024 vs. 2,946 in 2025). For AF detection, 15,910 diabetes patients were screened for AF. Based on a local study reporting a 0.2% AF detection rate among these patients, approximately 30 patients were identified as having AF. For AF assessment, 143 TTE were performed during the review period. 13 patients (9%) required referral to secondary care for significant valvular pathology or cardiomyopathy. For prevention of stroke and thromboembolism, 47% of the patients (1,383 out of 2,946) were prescribed NOACs with continued reassessment. Furthermore, 39 patients on NOACs had received drug review and counselling by pharmacists over a 6-month period. Conclusion:
Through persistent enhancements to our services, we could now offer AF patients streamlined access to timely, convenient, and comprehensive assessment and management within primary care and reduce the burden in secondary care
