Screening for undiagnosed atrial fibrillation in the community

Current Opinion in Cardiology

Volumn 29, Issue 1, 2014, Pages 28-35

  Quinn, F Russell ^a   Gladstone, David ^b  

^a LIBIN CARDIOVASCULAR INSTITUTE OF ALBERTA   (Canada)

^b SUNNYBROOK RESEARCH INSTITUTE   (Canada)

Author keywords

ambulatory ECG; atrial fibrillation; screening; stroke; systemic embolism

Indexed keywords

ANTICOAGULANT AGENT;

CARDIOVASCULAR RISK; CEREBROVASCULAR ACCIDENT; CHADS2 SCORE; DIAGNOSTIC ACCURACY; ELECTROCARDIOGRAM; ELECTROCARDIOGRAPHY MONITORING; ELECTRODE; EMBOLISM; HEALTH PROGRAM; HEART ATRIUM FIBRILLATION; HUMAN; HYPERTENSION; PATIENT MONITORING; PREVALENCE; PRIORITY JOURNAL; RECOMMENDED DRUG DOSE; REVIEW; SCREENING TEST; SENSITIVITY AND SPECIFICITY; THROMBOSIS;

ASYMPTOMATIC DISEASES; ATRIAL FIBRILLATION; ELECTROCARDIOGRAPHY; ELECTROCARDIOGRAPHY, AMBULATORY; HUMANS; MASS SCREENING; RISK FACTORS;

EID: 84890433146     PISSN: 02684705     EISSN: 15317080     Source Type: Journal    
DOI: 10.1097/HCO.0000000000000018     Document Type: Review

References (32)

1. Lloyd-Jones DM, Wang TJ, Leip EP, et al. Lifetime risk for development of atrial fibrillation: The Framingham Heart Study. Circulation 2004; 110:1042-1046.
2. Andersson T, Magnuson A, Bryngelsson I, et al. All-cause mortality in 272 186 patients hospitalized with incident atrial fibrillation 1995-2008: A Swedish nationwide long-termcase-control study. Eur Heart J 2013; 34:1061-1067. This large study with long follow-up confirms atrial fibrillation as an independent predictor of mortality, especially inwomenand those with a younger age at diagnosis.
3. Camm AJ, Lip GY, De Caterina R, 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; 33:2719-2747. An update incorporating new information to give clear guidance on assessment of stroke risk, bleeding risk and appropriate choice of anticoagulation. First international guideline to recommend screening for atrial fibrillation in those aged at least 65 years.
4. Davis RC, Hobbs FD, Kenkre JE, et al. Prevalence of atrial fibrillation in the general population and in high-risk groups: The ECHOES study. Europace 2012; 14:1553-1559. This study presents contemporary data on the prevalence of atrial fibrillation in the general population and in patients with certain comorbid conditions. This study provides important baseline data when considering appropriate groups to target for atrial fibrillation screening.
5. Kalantarian S, Stern TA, Mansour M, Ruskin JN. Cognitive impairment associated with atrial fibrillation: A meta-analysis. Ann Intern Med 2013; 158:338-346. An important demonstration of the association between the presence of atrial fibrillation and cognitive impairment, irrespective of whether the patient has a clinical history of stroke.
6. 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.
7. Skanes AC, Healey JS, Cairns JA, et al. Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: Recommendations for stroke prevention and rate/rhythm control. Can J Cardiol 2012; 28:125-136. This guideline highlights important changes in the recommendations for anticoagulation of patients with atrial fibrillation, based on more accurate determination of those who are truly low risk. Most other patients are recommended to be anticoagulated with warfarin or one of the novel anticoagulant agents.
8. Fuster V, Rydén LE, Cannom DS, et al. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 123:e269-e367.
9. Healey JS, Connolly SJ, Gold MR, et al. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012; 366:120-129. A landmark study demonstrating that 'silent' atrial arrhythmias are common in patients with pacemakers or defibrillators and are associated with significant morbidity. Strategies to detect asymptomatic atrial fibrillation could therefore be an important step towards prevention of stroke, although trials to prove this have not yet been performed.
10. Lowres N, Neubeck L, Redfern J, Freedman SB. Screening to identify unknown atrial fibrillation: A systematic review. Thromb Haemost 2013; 110:213-222. Data presented show a 1% prevalence of previously undiagnosed atrial fibrillation in the general population, rising to 1.4% for those at least 65 years old. Two-thirds of those with silent atrial fibrillation were at a high risk of stroke, emphasizing the fact that detecting these patients could lead to meaningful changes in therapy.
11. Burgess C, Ingham T, Woodbridge M, et al. The use of antithrombotics in patients presenting with stroke and atrial fibrillation. Ther Clin Risk Manag 2007; 3:491-498.
12. Glotzer TV, Daoud EG, Wyse DG, et al. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: The TRENDS study. Circ Arrhythm Electrophysiol 2009; 2:474-480.
13. Shanmugam N, Boerdlein A, Proff J, et al. Detection of atrial high-rate events by continuous home monitoring: Clinical significance in the heart failurecardiac resynchronization therapy population. Europace 2012; 14:230-237. Confirmation of the very high prevalence of atrial fibrillation in heart failure patients with implanted resynchronization therapy devices, and the clinical impact of this dysrhythmia. This is a particularly high-risk group of patients.
14. 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 2013; 164:371-372. One of the few studies to document the baseline stroke risk score for patients with previously undiagnosed atrial fibrillation. This study also highlighted a clear gap in therapy; no patients with previously undiagnosed atrial fibrillation and a CHA2DS2-VASc score of at least 2 were on anticoagulation.
15. Engdahl J, Andersson L, Mirskaya M, Rosenqvist M. Stepwise screening of atrial fibrillation in a 75-year-old population: Implications for stroke prevention. Circulation 2013; 127:930-937. This study demonstrates the benefits of a stratified screening strategy for atrial fibrillation, with prolonged monitoring for high-risk patients who do not show atrial fibrillation on an initial ECG. This is an important step, as screening at a single time point is likely to miss many patients with intermittent atrial fibrillation. The study also embraces the use of new technology for atrial fibrillation screening.
16. Hart RG, Pearce LA, Rothbart RM, et al. Stroke with intermittent atrial fibrillation: Incidence and predictors during aspirin therapy. J Am Coll Cardiol 2000; 35:183-187.
17. Hohnloser SH, Pajitnev D, Pogue J, et al. Incidence of stroke in paroxysmal versus sustained atrial fibrillation in patients taking oral anticoagulation or combined antiplatelet therapy: An ACTIVE W Substudy. J Am Coll Cardiol 2007; 50:2156-2161.
18. 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.
19. Kaleschke G, Hoffmann B, Drewitz I, et al. Prospective, multicentre validation of a simple, patient-operated electrocardiographic system for the detection of arrhythmias and electrocardiographic changes. Europace 2009; 11:1362-1368.
20. McManus DD, Lee J, Maitas O, et al. A novel application for the detection of an irregular pulse using an iPhone 4S in patients with atrial fibrillation. Heart Rhythm 2013; 10:315-319. This is a neat demonstration that algorithms can be developed to detect atrial fibrillation making use of the technology that many patients already carry.
21. 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; 165:193-194. This study shows that acceptable ECG tracings for the diagnosis of atrial fibrillation can be obtained from an iPhone case with dry electrodes.
22. 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. BMJ Open 2012; 2:1-6.
23. Marazzi G, Iellamo F, Volterrani M, et al. Comparison of Microlife BP A200 Plus and Omron M6 blood pressure monitors to detect atrial fibrillation in hypertensive patients. Adv Ther 2012; 29:64-70.
24. Wiesel J, Abraham S, Messineo FC. Screening for asymptomatic atrial fibrillation while monitoring the blood pressure at home: Trial of regular versus irregular pulse for prevention of stroke (TRIPPS 2.0). Am J Cardiol 2013; 111:1598-1601. This study demonstrates good sensitivity and specificity of home-based atrial fibrillation detection using an automated BP machine compared with tracings from an ECG event recorder.
25. Wiesel J, Fitzig L, Herschman Y, Messineo FC. Detection of atrial fibrillation using a modified microlife blood pressure monitor. Am J Hypertens 2009; 22:848-852.
26. Harris K, Edwards D, Mant J. How can we best detect atrial fibrillation J Royal Coll Phys Edinburgh 2012; 42:5-22. This is a thorough review of atrial fibrillation screening strategies, methods and technologies. Clinically relevant recommendations are made on the basis of the evidence to date.
27. Barrett L. Health and caregiving among the 50: Ownership, use and interest in mobile technology. AARP Res Strategy Anal 2011. [online]. http://assets. aarp.org/rgcenter/general/health-caregiving-mobile-technology.pdf [Accessed 11 September 2013]
28. Marinigh R, Lip GY, Fiotti N, et al. Age as a risk factor for stroke in atrial fibrillation patients: Implications for thromboprophylaxis. J Am Coll Cardiol 2010; 56:827-837.
29. Van Walraven C, Hart RG, Connolly S, et al. Effect of age on stroke prevention therapy in patients with atrial fibrillation: The atrial fibrillation investigators. Stroke 2009; 40:1410-1416.
30. Seet RC, Friedman PA, Rabinstein AA. Prolonged rhythm monitoring for the detection of occult paroxysmal atrial fibrillation in ischemic stroke of unknown cause. Circulation 2011; 124:477-486.
31. Botto GL, Padeletti L, Santini M, et al. Presence and duration of atrial fibrillation detected by continuous monitoring: Crucial implications for the risk of thromboembolic events. J Cardiovasc Electrophysiol 2009; 20:241-248.
32. Cowan C, Healicon R, Robson I, et al. The use of anticoagulants in the management of atrial fibrillation among general practices in England. Heart 2013; 99:1166-1172. This study demonstrates the utility of large patient databases for deriving data on anticoagulant use. It also highlights the underutilization of anticoagulation in eligible patients.