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Screening strategies for atrial fibrillation in the elderly population: a systematic review and network meta-analysis

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Abstract

Opportunistic screening for atrial fibrillation (AF) is currently recommended for patients aged 65 years and older. However, this has recently been called into question by two studies that report that opportunistic screening is no more effective than usual care. Furthermore, there seems to be no consensus on which is the most effective screening strategy (opportunistic or systematic). Thus, we aimed to compare the different AF detection strategies with each other using the methodology of systematic review with network meta-analysis. An electronic database search of MEDLINE, CENTRAL, and EMBASE was performed. In addition, we also searched OpenGrey, experts’ knowledge and screened the reference list of included studies or other relevant publications. The search was performed on the 2nd of November of 2020 and updated on the 20th of September of 2021. We performed a random-effects pairwise meta-analysis and a random-effects network meta-analysis within a frequentist framework in an intention to screen analysis. We reported the results as relative risk (RR) with 95% confidence intervals (CI). We assessed the confidence in the evidence using the GRADE framework. Nine studies were included, enrolling 80,665 participants. Pooled effect sizes suggested that systematic screening was effective when compared with usual care (RR 2.11; 95% CI 1.48–3.02; high GRADE confidence) and when compared with opportunistic screening (RR 1.86; CI 1.23–2.82; high GRADE confidence) but no significant difference was found between opportunistic screening and usual care (RR 1.13; 95% CI 0.79–1.63; low GRADE confidence). Systematic screening was the most effective strategy for detecting atrial fibrillation in individuals aged 65 years or older. Opportunistic screening was no more effective than usual care, but the results were weakened by a low quality of evidence due to risk of bias of the included studies and imprecision in the results. PROSPERO registration number: CRD42020218672.

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References

  1. Zoni-Berisso M, Lercari F, Carazza T, Domenicucci S (2014) Epidemiology of atrial fibrillation: European perspective. Clin Epidemiol 6(1):213. https://doi.org/10.2147/CLEP.S47385

    Article  PubMed  PubMed Central  Google Scholar 

  2. Miyasaka Y et al (2006) Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 114(2):119–125. https://doi.org/10.1161/CIRCULATIONAHA.105.595140

    Article  PubMed  Google Scholar 

  3. Wolf PA, Abbott RD, Kannel WB (1991) Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 22(8):983–988. https://doi.org/10.1161/01.STR.22.8.983

    Article  CAS  PubMed  Google Scholar 

  4. Fay MR, Fitzmaurice DA, Freedman B (2017) Screening of older patients for atrial fibrillation in general practice: current evidence and its implications for future practice. Eur J General Pract 23(1):246–253. https://doi.org/10.1080/13814788.2017.1374366 (Taylor and Francis Ltd)

    Article  Google Scholar 

  5. Grogan M, Smith HC, Gersh BJ, Wood DL (1992) Left ventricular dysfunction due to atrial fibrillation in patients initially believed to have idiopathic dilated cardiomyopathy. Am J Cardiol 69(19):1570–1573. https://doi.org/10.1016/0002-9149(92)90705-4

    Article  CAS  PubMed  Google Scholar 

  6. Wang TJ et al (2003) Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality. Circulation 107(23):2920–2925. https://doi.org/10.1161/01.CIR.0000072767.89944.6E

    Article  PubMed  Google Scholar 

  7. Bunch TJ et al (2010) Atrial fibrillation is independently associated with senile, vascular, and Alzheimer’s dementia. Hear Rhythm 7(4):433–437. https://doi.org/10.1016/J.HRTHM.2009.12.004

    Article  Google Scholar 

  8. Freeman JV, Wang Y, Akar J, Desai N, Krumholz H (2017) National trends in atrial fibrillation hospitalization, readmission, and mortality for Medicare beneficiaries, 1999–2013. Circulation 135(13):1227–1239. https://doi.org/10.1161/CIRCULATIONAHA.116.022388

    Article  PubMed  Google Scholar 

  9. Lee E et al (2018) Mortality and causes of death in patients with atrial fibrillation: a nationwide population-based study. PLoS ONE. https://doi.org/10.1371/JOURNAL.PONE.0209687

    Article  PubMed  PubMed Central  Google Scholar 

  10. Flaker GC et al (2005) Asymptomatic atrial fibrillation: demographic features and prognostic information from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Am Heart J 149(4):657–663. https://doi.org/10.1016/J.AHJ.2004.06.032

    Article  PubMed  Google Scholar 

  11. Gibbs H et al (2021) Clinical outcomes in asymptomatic and symptomatic atrial fibrillation presentations in GARFIELD-AF: implications for AF screening. Am J Med 134(7):893-901.e11. https://doi.org/10.1016/J.AMJMED.2021.01.017

    Article  CAS  PubMed  Google Scholar 

  12. Potpara TS, Polovina MM, Marinkovic JM, Lip GYH (2013) A comparison of clinical characteristics and long-term prognosis in asymptomatic and symptomatic patients with first-diagnosed atrial fibrillation: the Belgrade Atrial Fibrillation Study. Int J Cardiol 168(5):4744–4749. https://doi.org/10.1016/J.IJCARD.2013.07.234

    Article  PubMed  Google Scholar 

  13. Thind M et al (2018) Embolic and other adverse outcomes in symptomatic versus asymptomatic patients with atrial fibrillation (from the ORBIT-AF Registry). Am J Cardiol 122(10):1677–1683. https://doi.org/10.1016/J.AMJCARD.2018.07.045

    Article  PubMed  Google Scholar 

  14. Borowsky LH, Regan S, Chang Y, Ayres A, Greenberg SM, Singer DE (2017) First diagnosis of atrial fibrillation at the time of stroke. Cerebrovasc Dis 43(3–4):192–199. https://doi.org/10.1159/000457809

    Article  PubMed  Google Scholar 

  15. Sposato LA, Cipriano LE, Saposnik G, Vargas ER, Riccio PM, Hachinski V (2015) Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol 14(4):377–387. https://doi.org/10.1016/S1474-4422(15)70027-X

    Article  PubMed  Google Scholar 

  16. Krahn AD, Manfreda J, Tate RB, Mathewson FAL, Cuddy TE (1995) The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the manitoba follow-up study. Am J Med 98(5):476–484. https://doi.org/10.1016/S0002-9343(99)80348-9

    Article  CAS  PubMed  Google Scholar 

  17. Heeringa J et al (2006) Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 27(8):949–953. https://doi.org/10.1093/EURHEARTJ/EHI825

    Article  PubMed  Google Scholar 

  18. Mandalenakis Z et al (2015) The risk of atrial fibrillation in the general male population: a lifetime follow-up of 50-year-old men. EP Eur 17(7):1018–1022. https://doi.org/10.1093/EUROPACE/EUV036

    Article  Google Scholar 

  19. Schnabel RB et al (2015) Fifty-year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the community. Lancet (London, England) 386(9989):154. https://doi.org/10.1016/S0140-6736(14)61774-8

    Article  PubMed  Google Scholar 

  20. Turakhia MP et al (2015) Economic burden of undiagnosed nonvalvular atrial fibrillation in the United States. Am J Cardiol 116(5):733–739. https://doi.org/10.1016/j.amjcard.2015.05.045

    Article  PubMed  Google Scholar 

  21. Duarte R et al (2020) Journals Library Lead-I ECG for detecting atrial fibrillation in patients with an irregular pulse using single time point testing: a systematic review and economic evaluation. Health Technol Assess. https://doi.org/10.3310/hta24030

    Article  PubMed  PubMed Central  Google Scholar 

  22. Svennberg E et al (2017) Safe automatic one-lead electrocardiogram analysis in screening for atrial fibrillation. Europace 19(9):1449–1453. https://doi.org/10.1093/europace/euw286

    Article  PubMed  Google Scholar 

  23. Uittenbogaart SB et al (2020) Opportunistic screening versus usual care for detection of atrial fibrillation in primary care: cluster randomised controlled trial. BMJ 370:m3208. https://doi.org/10.1136/bmj.m3208

    Article  PubMed  PubMed Central  Google Scholar 

  24. Petryszyn P et al (2019) Effectiveness of screening for atrial fibrillation and its determinants. A meta-analysis. PLoS ONE. https://doi.org/10.1371/JOURNAL.PONE.0213198

    Article  PubMed  PubMed Central  Google Scholar 

  25. Mairesse GH et al (2017) Screening for atrial fibrillation: a European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLAECE). Europace 19(10):1589–1623. https://doi.org/10.1093/europace/eux177 (Oxford University Press)

    Article  PubMed  Google Scholar 

  26. Hutton B et al (2015) The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 162(11):777–784. https://doi.org/10.7326/M14-2385

    Article  PubMed  Google Scholar 

  27. Sterne JAC et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. https://doi.org/10.1136/BMJ.L4898

    Article  PubMed  PubMed Central  Google Scholar 

  28. Benito L et al (2015) EARLY: a pilot study on early diagnosis of atrial fibrillation in a primary healthcare centre. EP Eur 17(11):1688–1693. https://doi.org/10.1093/EUROPACE/EUV146

    Article  Google Scholar 

  29. Fitzmaurice DA et al (2007) Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial. BMJ 335(7616):383. https://doi.org/10.1136/BMJ.39280.660567.55

    Article  PubMed  PubMed Central  Google Scholar 

  30. Gladstone DJ et al (2021) Screening for atrial fibrillation in the older population: a randomized clinical trial. JAMA Cardiol 6(5):558–567. https://doi.org/10.1001/jamacardio.2021.0038

    Article  PubMed  Google Scholar 

  31. Halcox JPJ et al (2017) Assessment of remote heart rhythm sampling using the AliveCor heart monitor to screen for atrial fibrillation the REHEARSE-AF study. Circulation 136(19):1784–1794. https://doi.org/10.1161/CIRCULATIONAHA.117.030583

    Article  PubMed  Google Scholar 

  32. Kaasenbrood F et al (2020) Opportunistic screening versus usual care for diagnosing atrial fibrillation in general practice: a cluster randomised controlled trial. Br J Gen Pract 70(695):e427–e433. https://doi.org/10.3399/bjgp20X708161

    Article  PubMed  PubMed Central  Google Scholar 

  33. Mancinetti M, Schukraft S, Faucherre Y, Cook S, Arroyo D, Puricel S (2021) Handheld ECG tracking of in-hOspital Atrial Fibrillation (HECTO-AF): a randomized controlled trial. Front Cardiovasc Med 8:681890. https://doi.org/10.3389/FCVM.2021.681890

    Article  PubMed  PubMed Central  Google Scholar 

  34. Morgan S and Mant D (2002) Randomised trial of two approaches to screening for atrial fibrillation in UK general practice. Br J Gen Pract 52(478)

  35. Svennberg E, Friberg L, Frykman V, Al-Khalili F, Engdahl J, Rosenqvist M (2021) Clinical outcomes in systematic screening for atrial fibrillation (STROKESTOP): a multicentre, parallel group, unmasked, randomised controlled trial. Lancet. https://doi.org/10.1016/S0140-6736(21)01637-8

    Article  PubMed  Google Scholar 

  36. Wilson J, Jungner G (1968) Principles and practice of screening for disease. Wold Health Organization, Switzerland, p 34 (Public Health Pap., 1968)

    Google Scholar 

  37. World Health Organization. Regional Office for Europe (2020) Screening programmes: a short guide. Increase effectiveness, maximize benefits and minimize harm. World Health Organization. Regional Office for Europe. https://apps.who.int/iris/handle/10665/330829

  38. Speechley M, Kunnilathu A, Aluckal E, Balakrishna MS, Mathew B, George EK (2017) Screening in Public health and clinical care: similarities and differences in definitions, types, and aims—a systematic review. J Clin Diagn Res 11(3):LE01. https://doi.org/10.7860/JCDR/2017/24811.9419

    Article  PubMed  PubMed Central  Google Scholar 

  39. Burdett P, Lip GYH (2022) Targeted vs full population screening costs for incident atrial fibrillation and AF-related stroke for a healthy population aged 65 years in the United Kingdom. Eur Hear J. https://doi.org/10.1093/EHJQCCO/QCAC005

    Article  Google Scholar 

  40. Hindricks G et al (2020) 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J. https://doi.org/10.1093/eurheartj/ehaa612

    Article  PubMed  PubMed Central  Google Scholar 

  41. Chan N-Y et al (2021) Guidelines 2021 Asia Pacific Heart Rhythm Society (APHRS) practice guidance on atrial fibrillation screening. J Arrhythmia. https://doi.org/10.1002/joa3.12669

    Article  Google Scholar 

  42. Welton NJ et al (2017) Screening strategies for atrial fibrillation: a systematic review and cost-effectiveness analysis. Health Technol Assess (Rockv) 21(29):1–236. https://doi.org/10.3310/HTA21290

    Article  Google Scholar 

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Funding

This project was funded by “Programa Educação pela Ciência” (PEC).

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Authors and Affiliations

  1. Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028, Lisbon, Portugal

    Rafael Whitfield, Raquel Ascenção, Gustavo Lima da Silva, Ana G. Almeida, Fausto J. Pinto & Daniel Caldeira

  2. Clínica Universitária de Medicina Geral e Familiar, Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal

    Raquel Ascenção

  3. Faculdade de Medicina, Centro Cardiovascular da Universidade de Lisboa-CCUL (CCUL@RISE), CAML, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028, Lisbon, Portugal

    Gustavo Lima da Silva, Ana G. Almeida, Fausto J. Pinto & Daniel Caldeira

  4. Serviço de Cardiologia, Departamento do Coração e Vasos, Hospital Universitário de Santa Maria-CHULN, Avenida Professor Egas Moniz, 1649-028, Lisbon, Portugal

    Gustavo Lima da Silva, Ana G. Almeida, Fausto J. Pinto & Daniel Caldeira

  5. Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028, Lisbon, Portugal

    Daniel Caldeira

  6. Centro de Estudos de Medicina Baseada na Evidência (CEMBE), Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028, Lisbon, Portugal

    Daniel Caldeira

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  1. Rafael Whitfield
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Correspondence to Daniel Caldeira.

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Daniel Caldeira has participated in educational meetings and/or attended conferences or symposia (including travel, accommodation, and/or hospitality) with Bristol-Myers Squibb, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Merck Serono, Ferrer, Pfizer, Novartis, and Roche. The remaining authors do not have interests to disclose.

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Whitfield, R., Ascenção, R., da Silva, G.L. et al. Screening strategies for atrial fibrillation in the elderly population: a systematic review and network meta-analysis. Clin Res Cardiol 112, 705–715 (2023). https://doi.org/10.1007/s00392-022-02117-9

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