Screening for Atrial Fibrillation

Many strokes may be prevented by detecting asymptomatic atrial fibrillation (AF), as many cases of AF are only diagnosed at the time of first stroke. Screening would help to identify these asymptomatic patients, so these patients can initiate appropriate effective therapy, such as oral anticoagulants (OACs). It is recognized that health resources vary widely between countries and health systems, so the setting for AF-screening should be both country- and health system-specific. This white paper provides advocacy for implementation of AF-screening at this moment, and remarks that large randomized outcome studies would be helpful to strengthen the evidence base. The paper was written by expert members of the AF-SCREEN, an international collaboration of various kinds of health care professionals that aims for AF-screening to reduce the number of strokes and death.

First, an overview is given based on published studies on the incidence of screen-detected AF, the risk of stroke and death that individuals with incidentally detected asymptomatic AF or cardiac implanted electronic device (CIED)-detected atrial high-rate episodes have, and treatment efficacy in these patients. Then, the relation of AF with ischemic stroke is discussed and the document elaborates on different screening aspects based on known clinical data. This includes cost-effectiveness, selection of patients, subgroups of patients, different screening methods and settings to best perform screening. In addition, next to the identification and treatment of asymptomatic cases with AF, it is highlighted that there should also be screened for undertreatment of patients with known AF, as population surveys indicate that treatment remains suboptimal with large country differences. At last, patient awareness and preferences are discussed.

The document closes with policies of current guidelines, in which the ESC recommends opportunistic pulse-taking in all patients 65 years or older or in high-risk subgroups, followed by an ECG if irregular. Also, the National Institute for Health and Care Excellence (UK) guidelines recommend pulse-taking, but only for symptoms. Furthermore, the new 2016 ESC guideline now also includes an ECG rhythm strip for at least 72 hours for patients after a transient ischemic attack or stroke with additional longer term monitoring considered, as well as consideration of systematic screening in patients 75 years or older or those at high risk for stroke. On the other hand, the ACC/AHA/HRS guidelines make no recommendation on the topic of screening.

Find this article online at Circulation