1
University of Sydney, ANZAC Research Institute and Department of Cardiology, Concord Hospital, Sydney, New South Wales, Australia
,
Lis Neubeck
2
The George Institute for Global Health, Sydney, New South Wales, Australia
,
Julie Redfern
2
The George Institute for Global Health, Sydney, New South Wales, Australia
,
S. Ben Freedman
1
University of Sydney, ANZAC Research Institute and Department of Cardiology, Concord Hospital, Sydney, New South Wales, Australia
› Author AffiliationsFinancial support: NL is funded by a National Heart Foundation Postgraduate Scholarship (PP12S6990). LN is funded by an NHMRC early career fellowship (1036763). JR is funded by a Postdoctoral Fellowship co-funded by the NHMRC and National Heart Foundation (632933).
Atrial fibrillation (AF) is associated with a significantly increased stroke risk which is highly preventable with appropriate oral anticoagulant therapy (OAC). However, AF may be asymptomatic and unrecognised prior to stroke. We aimed to determine if single time-point screening for AF could identify sufficient numbers with previously undiagnosed AF, to be effective for stroke prevention. This is a systematic review of clinical trials, by searching electronic medical databases, reference lists and grey literature. Studies were included if they evaluated a general ambulant adult population, using electrocardiography or pulse palpation to identify AF. We identified 30 individual studies (n=122,571, mean age 64 years, 54% male) in nine countries. Participants were recruited either from general practitioner and outpatient clinics (12 studies) or population screening/community advertisements (18 studies). Prevalence of AF across all studies was 2.3% (95% CI, 2.2–2.4%), increasing to 4.4% (CI, 4.1–4.6%) in those ≥65 years (16 studies, n= 27,884). Overall incidence of previously unknown AF (14 studies, n=67,772) was 1.0% (CI, 0.89–1.04%), increasing to 1.4% (CI, 1.2–1.6%) in those ≥65 years (8 studies, n= 18,189) in whom screening setting did not influence incidence identified. Of those with previously unknown AF, 67% were at high risk of stroke. Screening can identify 1.4% of the population ≥65 years with previously undiagnosed AF. Many of those identified would be eligible for, and benefit from OAC to prevent stroke. Given this incidence, community AF screening strategies in at risk older age groups could potentially reduce the overall health burden associated with AF.
1
Heeringa J,
van der Kuip DAM,
Hofman A.
et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 2006; 27: 949-953.
2
Miyasaka Y,
Barnes ME,
Gersh BJ.
et al. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 2006; 114: 119-125.
3
Chugh SS,
Blackshear JL,
Shen W-K.
et al. Epidemiology and natural history of atrial fibrillation: clinical implications. J Am Coll Cardiol 2001; 37: 371-378.
4
Miyasaka Y,
Barnes ME,
Gersh BJ.
et al. Time trends of ischemic stroke incidence and mortality in patients diagnosed with first atrial fibrillation in 1980 to 2000: report of a community-based study. Stroke 2005; 36: 2362-2366.
5
Hannon N,
Sheehan O,
Kelly L.
et al. Stroke associated with atrial fibrillation – incidence and early outcomes in the North Dublin population stroke study. Cerebrovasc Dis 2010; 29: 43-49.
6
Flint AC,
Banki NM,
Ren X.
et al. Detection of paroxysmal atrial fibrillation by 30-day event monitoring in cryptogenic ischemic stroke: The Stroke and Monitoring for PAF in Real Time (SMART) registry. Stroke 2012; 43: 2788-2790.
9
Kimura K,
Minematsu K,
Yamaguchi T.
Atrial fibrillation as a predictive factor for severe stroke and early death in 15 831 patients with acute ischaemic stroke. J Neurol Neurosurg Psych 2005; 76: 679-683.
11
Hart RG,
Pearce LA,
Aguilar MI.
Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007; 146: 857-867.
16
Deif B,
Lowres N,
Freedman SB.
Screening for atrial fibrillation above age 65 detects an asymptomatic subset at high risk of stroke. Int J Cardiol. 2012 Epub ahead of print.
17
Engdahl J,
Andersson L,
Mirskaya M.
et al. Stepwise screening for atrial fibrillation in a 75-year old population and implications for stroke prevention. Circ. 2013 Epub ahead of print.
18
Camm AJ,
Lip GYH,
Caterina RD.
et al. 2012 focused update of the ESC guidelines for the management of atrial fibrillation. An update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 14: 1385-1413.
19
Elm Ev,
Altman DG,
Egger M.
et al. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Br Med J 2007; 335: 806-808.
20
Sanmartín M,
Fraguela FFraga,
Martín-Santos Á.
et al. A campaign for information and diagnosis of atrial fibrillation: “Pulse Week”. Rev Esp Cardiol (English Edition) 2013; 66: 34-38.
21
Gomez-Doblas JJ,
Muniz J,
Alonso J.
et al. Prevalence of atrial fibrillation in Spain. Preliminary results of the OFRECE study [abstract]. Eur Heart J 2012; 33 (Suppl): 377.
22
Gill PS,
Calvert M,
Davis R.
et al. Prevalence of heart failure and atrial fibrillation in minority ethnic subjects: The Ethnic-Echocardiographic Heart of England Screening Study (E-ECHOES). PLoS ONE 2011; 06: e26710.
23
Sudlow M,
Rodgers H,
Kenny RA.
et al. Identification of patients with atrial fibrillation in general practice: a study of screening methods. Br Med J 1998; 317: 327-328.
25
Hill J,
Mottram E,
Killeen P.
Study of the prevalence of atrial fibrillation in general practice patients over 65 years of age. J R Coll Gen Pract 1987; 37: 172-173.
27
Levitt G.
The electrocardiogram in the aged: A study of 100 men and women over the age of 70 with apparently normal hearts. Am Heart J 1939; 18: 692-696.
28
Carrington M,
Jennings G,
Clark R.
et al. Assessing cardiovascular risk in regional areas: the healthy hearts -- beyond city limits program. BMC Health Serv Res 2012; 12: 296.
29
Claes N,
Van Laethem C,
Goethals M.
et al. Prevalence of atrial fibrillation in adults participating in a large-scale voluntary screening programme in Belgium. Acta Cardiol 2012; 67: 273-278.
30
Schnabel RB,
Wilde S,
Wild PS.
et al. Atrial fibrillation: its prevalence and risk factor profile in the german general population. Dtsch Arztebl Int 2012; 109: 293-299.
31
Meschia JF,
Merrill PBS,
Soliman EZ.
et al. Racial disparities in awareness and treatment of atrial fibrillation: the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Stroke 2010; 41: 581-587.
32
Doliwa PS,
Frykman V,
Rosenqvist M.
Short-term ECG for out of hospital detection of silent atrial fibrillation episodes. Scand Cardiovasc J 2009; 43: 163-168.
33
Lavenson Jr. GS,
Pantera RL,
Garza RM.
et al. Development and implementation of a rapid, accurate, and cost-effective protocol for national stroke prevention screening. Am J Surg 2004; 188: 638-643.
34
Munschauer 3rd FE,
Sohocki D,
Smith SCarrow.
et al. A community education program on atrial fibrillation: Implications of pulse self-examination on awareness and behavior. J Stroke Cerebrovasc Dis 2004; 13: 208-213.
35
DeLemos CD,
Atkinson RP,
Croopnick SL.
et al. How effective are “community” stroke screening programs at improving stroke knowledge and prevention practices?: Results of a 3-Month follow-up study. Stroke 2003; 34: 247-249.
37
Wolf PA,
Benhamin EJ,
Belanger AJ.
et al. Secular trends in the prevalence of atrial fibrillation: The Framingham study. Am Heart J 1995; 131: 790-795.
38
Furberg CD,
Psaty BM,
Manolio TA.
et al. Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study). Am J Cardiol 1994; 74: 236-241.
42
Ostrander Jr. LD,
Brandt RL,
Kjelsberg MO.
et al. Electrocardiographic findings among the adult population of a total natural community, Tecumseh, Michigan. Circ 1965; 31: 888-898.
45
Fitzmaurice DA,
Hobbs FDR,
Jowett S.
et al. Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial. Br Med J 2007; 335: 383.
46
Morgan S,
Mant D.
Randomised trial of two approaches to screening for atrial fibrillation in UK general practice. Br J Gen Pract 2002; 52: 373-374 377-380.
47
Wilke T,
Groth A,
Mueller S.
et al. Oral anticoagulation use by patients with atrial fibrillation in Germany. Adherence to guidelines, causes of anticoagulation under-use and its clinical outcomes, based on claims-data of 183,448 patients. Thromb Haemost 2012; 107: 1053-1065.
48
Miyasaka Y,
Barnes ME,
Bailey KR.
et al. Mortality trends in patients diagnosed with first atrial fibrillation: a 21-year community-based study. J Am Coll Cardiol 2007; 49: 986-992.
49
Stott DJ,
Dewar RI,
Garratt CJ.
et al. RCPE UK Consensus Conference on ‘Approaching the comprehensive management of atrial fibrillation: evolution or revolution?’. J R Coll Physicians Edinb 2012; 42 (Suppl. 18) 3-4.
50
Maeda K,
Shimbo T,
Fukui T.
Cost-effectiveness of a community-based screening programme for chronic atrial fibrillation in Japan. J Med Screen 2004; 11: 97-102.
51
Hobbs FDR,
Fitzmaurice DA,
Mant J.
et al. A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Health Technol Assess 2005; 09: 1-74.
52
Lau JK,
Lowres N,
Neubeck L.
et al. iPhone ECG application for community screening to detect silent atrial fibrillation: A novel technology to prevent stroke. Int J Cardiol. 2013 Epub ahead of print.
53
Wiesel J,
Fitzig L,
Herschman Y.
et al. Detection of atrial fibrillation using a modified microlife blood pressure monitor. Am J Hypertens 2009; 22: 848-852.
54
Lewis M,
Parker D,
Weston C.
et al. Screening for atrial fibrillation: sensitivity and specificity of a new methodology. Br J Gen Pract 2011; 61: 38-39.
56
Lowres N,
Freedman SB,
Redfern J.
et al. Screening Education And Recognition in Community pHarmacies of Atrial Fibrillation to prevent stroke in an ambulant population aged ≥65 years (SEARCH-AF stroke prevention study): a cross-sectional study protocol. Br Med J Open 2012; 02: 3.
57
Liao J,
Khalid Z,
Scallan C.
et al. Noninvasive cardiac monitoring for detecting paroxysmal atrial fibrillation or flutter after acute ischemic stroke: a systematic review. Stroke 2007; 38: 2935-2940.
58
Olesen JB,
Torp-Pedersen C,
Hansen ML.
et al. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0–1: A nationwide cohort study. Thromb Haemost. 2012 107. 1009-1194.
59
Potpara TS,
Stankovic GR,
Beleslin BD.
et al. A 12-year follow-up study of patients with newly diagnosed lone atrial fibrillation. Implications of arrhythmia progression on prognosis: the Belgrade atrial fibrillation study. Chest 2012; 141: 339-347.
60
Banerjee A,
Lane DA,
Torp-Pedersen C.
et al. Net clinical benefit of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus no treatment in a ‘real world’ atrial fibrillation population: a modelling analysis based on a nationwide cohort study. Thromb Haemost 2012; 107: 584-589.