High-intensity atrial fibrillation screening to prevent stroke

Abstract

Opportunistic single-timepoint screening for atrial fibrillation is guideline-recommended in people aged 65 years and older to prevent cardioembolic stroke. 1 Hindricks G Potpara T Dagres N et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021; 42: 373-498 Crossref PubMed Scopus (2525) Google Scholar Such screening is easily done by taking the pulse or by handheld electrocardiogram (ECG) in primary care as part of routine practice, 2 Freedman B Hindricks G Banerjee A et al. World Heart Federation roadmap on atrial fibrillation—a 2020 update. Glob Heart. 2021; 16: 41 Crossref PubMed Google Scholar although it is infrequently performed. 3 Freedman B Schnabel R Calkins H Opportunistic electrocardiogram screening for atrial fibrillation to prevent stroke. JAMA Cardiol. 2019; 4: 91-92 Crossref PubMed Scopus (15) Google Scholar The stroke risk of atrial fibrillation detected on single-timepoint screening, and the reduction of this risk by oral anticoagulant thromboprophylaxis, is approximated by incidentally detected asymptomatic atrial fibrillation. This incidentally detected atrial fibrillation has the same level of risk as symptomatic atrial fibrillation presentations. 4 Gibbs H Freedman B Rosenqvist M et al. Clinical outcomes in asymptomatic and symptomatic atrial fibrillation presentations in GARFIELD-AF: implications for AF screening. Am J Med. 2021; 134: 893-901.e11 Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar , 5 Wallenhorst C Martinez C Freedman B Risk of ischemic stroke in asymptomatic atrial fibrillation incidentally-detected in primary care compared with other clinical presentations. Thromb Haemost. 2021; (published online June 30.)https://doi.org/10.1055/a-1541-3885 Google Scholar Although single-timepoint screening detects (largely persistent) atrial fibrillation in 1·4% of individuals aged 65 years and older, 6 Lowres N Olivier J Chao TF et al. Estimated stroke risk, yield, and number needed to screen for atrial fibrillation detected through single time screening: a multicountry patient-level meta-analysis of 141,220 screened individuals. PLoS Med. 2019; 16e1002903 Crossref PubMed Scopus (73) Google Scholar paroxysmal atrial fibrillation is often unrecognised and requires more intensive surveillance for detection. 3 Freedman B Schnabel R Calkins H Opportunistic electrocardiogram screening for atrial fibrillation to prevent stroke. JAMA Cardiol. 2019; 4: 91-92 Crossref PubMed Scopus (15) Google Scholar Intermittent handheld ECG self-screening as in STROKESTOP 3 Freedman B Schnabel R Calkins H Opportunistic electrocardiogram screening for atrial fibrillation to prevent stroke. JAMA Cardiol. 2019; 4: 91-92 Crossref PubMed Scopus (15) Google Scholar , 7 Svennberg E Friberg L Frykman V Al-Khalili F Engdahl J Rosenqvist M Clinical outcomes in systematic screening for atrial fibrillation (STROKESTOP): a multicentre, parallel group, unmasked, randomised controlled trial. Lancet. 2021; (published online Aug 29.)https://doi.org/10.1016/S0140-6736(21)01637-8 Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar or 2–4 weeks of continuous patch recording 3 Freedman B Schnabel R Calkins H Opportunistic electrocardiogram screening for atrial fibrillation to prevent stroke. JAMA Cardiol. 2019; 4: 91-92 Crossref PubMed Scopus (15) Google Scholar , 8 Quer G Freedman B Steinhubl SR Screening for atrial fibrillation: predicted sensitivity of short, intermittent electrocardiogram recordings in an asymptomatic at-risk population. Europace. 2020; 22: 1781-1787 Crossref PubMed Scopus (16) Google Scholar identifies an additional 2·5–4·0% of paroxysmal atrial fibrillation. By contrast, many more cases of atrial fibrillation are found by implanted cardiac monitors, sometimes referred to as implantable loop recorders (ILRs). 9 Freedman B Boriani G Glotzer TV Healey JS Kirchhof P Potpara TS Management of atrial high-rate episodes detected by cardiac implanted electronic devices. Nat Rev Cardiol. 2017; 14: 701-714 Crossref PubMed Scopus (69) Google Scholar Implantable loop recorder detection of atrial fibrillation to prevent stroke (The LOOP Study): a randomised controlled trialIn individuals with stroke risk factors, ILR screening resulted in a three-times increase in atrial fibrillation detection and anticoagulation initiation but no significant reduction in the risk of stroke or systemic arterial embolism. These findings might imply that not all atrial fibrillation is worth screening for, and not all screen-detected atrial fibrillation merits anticoagulation. Full-Text PDF