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Screening to Identify Atrial Fibrillation
A Focus on Screening to Improve Identification of Atrial Fibrillation

Released: May 17, 2023

Expiration: May 17, 2024

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Key Takeaways
  • According to the latest USPSTF update, there is insufficient evidence to assess the balance of benefits and harms in screening for atrial fibrillation (AF) in asymptomatic adults.
  • Prevention of AF is important with an increasingly aging population. Both patients and healthcare professionals (HCPs) can have a role in minimizing modifiable risk factors for AF.
  • Home wearable devices may have a limited role in screening for AF, and HCPs should become educated on the information that these devices can produce.

Atrial fibrillation (AF) is the most common cardiac arrhythmia and a major risk factor for ischemic stroke. Its prevalence increases with age: For adults younger than 55 years of age, the prevalence is <0.2%, but in people 85 years and older, the prevalence is closer to 10.0% according to the US Preventive Services Task Force (USPSTF) Recommendation Statement on Screening for Atrial Fibrillation from January 2022. In addition, the USPSTF states that 20% of strokes associated with AF are first diagnosed with AF either at the time of the stroke or shortly thereafter. Strokes from AF tend to be more severe than strokes caused by other etiologies. To prevent strokes from AF, healthcare professionals (HCPs) and patients can focus on prevention and screening.

Who Should Be Screened?
The USPSTF recently concluded that there is insufficient evidence to assess the balance of benefits and harms of screening for AF in asymptomatic adults in an update from its 2018 recommendation. This conclusion was not a change from the previous publications; however, in this recommendation, the USPSTF explored more forms of screening than just ECG. Furthermore, the VITAL-AF trial showed that widespread screening for AF with ECG did not improve the rate of use of anticoagulation. More evidence is needed to explore the thromboembolic risks associated with particular burdens of AF and to explore how screening may lead to improved outcomes, rather than just increased detection, before a responsible recommendation can be made.

It is important to assess risk factors when evaluating patients who might be appropriate to screen for AF. Risk factors for AF include, but are not limited to, older age (with a sharp incline in incidence after 65 years of age), obesity, diabetes, sleep apnea, smoking, cardiovascular disease, heart failure, and hypertension.

Once HCPs identify risk factors for AF, they can evaluate further by asking about signs and symptoms such as palpitations, fatigue, shortness of breath, and dizziness. Because the signs and symptoms of AF are often nonspecific, the HCP should be aware of the holistic picture of the patient, including history, risk factors, and physical examination findings.

It is also important to ensure that, if screening takes place, HCPs consider social determinants of health as part of the plan. HCPs should consider the patient’s needs to ensure adequate and timely follow-up. HCPs should evaluate the patient’s health literacy and educate the patient on signs and symptoms to look out for in case they experience an episode of AF or a stroke. Patients should understand the significance of why screening is being done, what the results may reveal, what AF could mean for them, and why follow-up is important.

Home Screening for AF
The simplest method of patient screening for AF is for a patient to self-monitor for symptoms that could be indicative of AF and to perform a pulse check after being educated on what is considered normal vs abnormal. Using an automated blood pressure cuff that has the ability to assess for an irregular heartbeat is another way for patients to self-screen for AF. Patients should be educated on how to use these devices if they have significant risk factors. Abnormalities with these at-home methods may indicate the need for further HCP-led screening. It is also important to educate patients that negative at-home screening methods do not rule out the possibility of AF.

Wearable devices for detecting AF are currently an expanding market, but more research is needed to determine the scope and relevance of these devices in screening for AF. Many of these devices are not approved by the FDA. Patients who have the highest risk for AF—older adults—may be less likely to purchase or wear them. It is important to provide education to patients on the benefits and limitations of using wearable devices, the cost, how to use them, the significance of alerts, and when it is appropriate to report the alerts to their HCPs. In turn, HCPs should be familiar with reading results from wearable devices, which may come in different formats, and interpreting the significance of these results. Wearable devices also may prove to be beneficial with earlier detection for patients with subclinical AF who are asymptomatic, although the risk of stroke associated with subclinical AF is not well established, so the impact of early detection in these patients is unknown.

Wearable devices, like generalized screening, also come with the potential for harm in the form of possible undue anxiety. Although they have the potential to help in screening, faulty alarms or those with no true clinical significance are certainly a possibility. Likewise, misinterpretation of the results of wearable devices may lead to misdiagnosis and/or unnecessary treatment. The prevalence of wearable devices is likely to increase in the future, and HCPs will need to know how to appropriately triage the information they produce. Of importance, HCPs also should recognize that they do not replace clinical testing for a formal diagnosis of AF. It has been projected by Kornej and colleagues that the prevalence of AF in the United States may reach 6-16 million by 2050, so HCPs should continue to seek evidence and information on when it is appropriate to screen patients for AF and ways to screen. In addition, the prevention of AF is important with an aging population. Both patients and HCPs can have a role in minimizing modifiable risk factors for AF.

Your Thoughts?
Do your patients have concerns related to their wearable device for AF? Join the conversation by answering the polling question and leaving a comment in the discussion box below.

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