Yield of diagnosis and risk of stroke with screening strategies for atrial fibrillation: a comprehensive review of current evidence

Abstract

Atrial fibrillation (AF) is the most prevalent arrhythmia worldwide. The presence of AF is associated with increased risk of systemic thromboembolism but with the uptake of oral anticoagulation (OAC) and implementation of a holistic and integrated care management, this risk is substantially reduced. The diagnosis of AF requires a 30-seconds long electrocardiographic (ECG) trace, irrespective of the presence of symptoms, which may represent the main indication for an ECG tracing. However, almost half patients are asymptomatic at the time of incidental AF diagnosis, with similar risk of stroke of those with clinical AF. This has led to crucial role of screening for AF, to increase the diagnosis of population at risk of clinical events. The aim of this review is to give a comprehensive overview about the epidemiology of asymptomatic AF, the different screening technologies, the yield of diagnosis in asymptomatic population and the benefit derived from screening in terms of reduction of clinical adverse events, such as stroke, cardiovascular and all-cause death. We aim to underline the importance of implementing AF screening programmes and reporting about the debate between scientific societies’ clinical guidelines recommendations and the concerns expressed by the regulatory authorities, which still do not recommend population-wide screening. This review summarises data on the ongoing trials specifically designed to investigate the benefit of screening in terms of risk of adverse events which will further elucidate the importance of screening in reducing risk of outcomes and influence and inform clinical practice in the next future.

Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal

“… 378 Use of mHealth solutions has been applied both to AF screening strategies and to clinical management and monitoring. 378 , 379 …”

“…Indeed, several data underlined how screening strategies have a significant yield of AF diagnosis, irrespective of the screening method and that very often these patients with asymptomatic AF have a high risk of stroke and thrombo-embolic events and are deemed to be prescribed with OAC drugs. 379 , 380 In this context, the use of simple and widespread digital technology solutions using photoplethysmography (PPG) appeared to be promising tools to be used in implementing large-scale screening programmes.…”

The feasibility of population screening for paroxysmal atrial fibrillation using hand-held electrocardiogram devices

“…Screening for atrial fibrillation (AF) through the use of pulse palpation or single-time point electrocardiograms (ECGs) has become incorporated as standard clinical practice in many countries as a means to reduce stroke, 1 , 2 although there is an absence of direct evidence that this leads to clinical benefit. 3 Indeed, recent trials have not demonstrated that this approach identifies more AF than usual care, in part due to improved AF detection in usual care compared with earlier trials.…”

The epidemiology and mortality of patients with atrial fibrillation: a complex landscape

“…1 The increased awareness of the risk of AF in the elderly has led to initiatives for AF screening and this is a factor that will affect the need to appropriately manage AF in the near future. 21,22 AF is a multifaceted and multisystem disease, with complex multidirectional interactions with its risk factors, associated comorbidities, lifestyle and the environment. The primary cause of death is usually not related to the arrhythmia itself nor to stroke, but instead to comorbidities and complications.…”

“…44,45 Of note, whatever approach is chosen, it is crucial to implement predefined, guideline-oriented clinical pathways for patients who have tested positive. 22,46 The interesting study by Zuin et al 30 was conducted before the COVID-19 pandemic that had a major impact on admission to hospitals for AF and AF management. 47 On the one hand, AF incidence increases in the setting of acute illnesses, 48,49 such as COVID-19, 50,51 and its pathogenesis involves a complex interplay between inflammation, prothrombotic state, hemodynamic changes, and sympathetic-vagal imbalances.…”