Population-Based Screening for Atrial Fibrillation

Abstract

Atrial fibrillation (AF) is a common and morbid arrhythmia. Stroke is a major hazard of AF and may be preventable with oral anticoagulation. Yet since AF is often asymptomatic, many individuals with AF may be unaware and do not receive treatment that could prevent a stroke. Screening for AF has gained substantial attention in recent years as several studies have demonstrated that screening is feasible. Advances in technology have enabled a variety of approaches to facilitate screening for AF using both medical-prescribed devices as well as consumer electronic devices capable of detecting AF. Yet controversy about the utility of AF screening remains owing to concerns about potential harms resulting from screening in the absence of randomized data demonstrating effectiveness of screening on outcomes such as stroke and bleeding. In this review, we summarize current literature, present technology, population-based screening considerations, and consensus guidelines addressing the role of AF screening in practice.

Keywords: atrial fibrillation; atrial flutter; attention; stroke; technology.

Figure 1.

Rationale, risks, and benefits of atrial fibrillation screening. The rationale for atrial fibrillation screening is depicted, as well as the relevant benefits (green) and risks (orange) expected with each approach. Individuals with undiagnosed incident AF are at risk for developing cardioembolic stroke prior to initiation of risk-based anticoagulation. Screening may lead to earlier diagnosis of AF, initiation of risk-based anticoagulation to prevent strokes, and an opportunity to institute risk factor modification strategies (e.g., weight loss, alcohol cessation, blood pressure control, sleep apnea management) to reduce AF symptoms and burden.^,,, For true positives (individuals with AF correctly identified as having AF using screening), the benefits may outweigh the risk of bleeding conferred by anticoagulation. For false positives (individuals without AF incorrectly identified as having AF using screening), the risk of bleeding likely outweighs any potential benefit of anticoagulation on non-AF related stroke. Without screening, fewer cases of otherwise undiagnosed AF will be identified, leading to lower overall bleeding risk from a lower rate of anticoagulation, but also more strokes resulting from unrecognized AF.

Figure 2.

Overview of atrial fibrillation screening modalities Depicted is a summary of established modalities for atrial fibrillation screening. Modalities in the top row (A-E) detect atrial fibrillation using intermittent assessment of cardiac rhythm, while modalities in the bottom row (F-H) detect atrial fibrillation through continuous monitoring.