Population Screening for AF is not Worthwhile. Jonathan P. Piccini, MD, MHS, FHRS Associate Professor of Medicine
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1 Population Screening for AF is not Worthwhile Jonathan P. Piccini, MD, MHS, FHRS Associate Professor of Medicine
2 Population Screening for AF is not Worthwhile Jonathan P. Piccini, MD, MHS, FHRS Associate Professor of Medicine
3 Relevant Disclosures (related to AF) Grants for research AHRQ ARCA biopharma Boston Scientific German AFNet Gilead Johnson & Johnson ResMed St Jude Medical Consulting Medtronic Pfizer/BMS Laguna Pharmaceuticals
4 Age-adjusted survival after new-onset AF by decade in men & women Schnabel RB. Lancet. 2015;386:
5 5
6 Population Based Screening Perception Reality
7 1. We don t even treat the patients we know have AF 7
8 Oral Anticoagulation is Underutilized in AF Patients at Risk for Stroke Curr Opin Cardiol. 2010;25:
9 2. Diagnosis is not as simple or easy as it seems 9
10 10
11 Screening for AF in people 65 & older Pulse check Sensivity 87%, Specificity 81% EKG (general MD) Sensitivity 92%, Specificity 91% Pulse & EKG Combined Sensitivity = 80% (87% X 92%), Specificity = 91% SPH for NHS. Screening for Atrial Fibrillation in People aged 65 and over. May,
12 3. Aggregate evidence does not support population-based screening. 12
13 veness of systematic screening for the detection of Effectiveness atrial fibrillation (Review) of systematic screening Moran PS, Flattery MJ, Teljeur C, Ryan M, Smith SM for detection of AF Systematic screening OR 1.57 ( ) Uptake 53% NNS 172 Opportunistic screening OR 1.58 ( ) Uptake 46% NNS 167 Both have comparable impact but systematic has >> cost Moran PS. Cochrane Review
14 4. Do we have any randomized controlled trials of screening in high-risk patients? 14
15 RCT of systematic screening (targeted & population) versus routine practice for the detection of AF (SAFE) Flag chart At risk patients: CHF HTN Rheumatic dz DM CAD Stroke/TIA Invitation to screening visit Hobbs FDR. Health Technology Assessment. October,
16 RCT of systematic screening: SAFE Results Arm Incidence of AF (% per year) Incremental Cost Control 1.04 ( ) Interventional Opportunistic 1.64 ( ) 337 Systematic 1.62 ( ) 3520 Hobbs FDR. Health Technology Assessment. October,
17 .... but surely the results would be different with continuous monitoring technologies right? 17
18 IMPACT of Device Monitoring Guided Anticoagulation on Stroke 2,700 patients CHADS2 1 Ip J. Am Heart J. 2009;158: e1.
19 Anticoagulation Protocol Intervention Group Any AT CHADS 2 1 & 2 Start OAC Stop OAC AT for 48h No AT for 30d Any AT Continuous remote monitoring for AT (36 of 48 atrial beats 200 bpm) CHADS 2 3 & 4 Start OAC Stop OAC AT for 24h in 2d No AT for 90d Martin DT. Eur Heart J. 2015;36: CHADS 2 5 & 6 (or prior TE) Any AT Start and maintain OAC
20 Event-free Survival (%) Primary Outcome Events N, Events 80 0 Control Intervention p = Time (years) Control 1361, 0 928, , , 57 75, 60 2, 61 Intervention 1357, 0 906, , , 59 66, 62 3, 63 Martin DT. Eur Heart J. 2015;36:
21 Back to opportunistic or risk-focused screening 21
22 Cryptogenic Stroke & Underlying AF: CRYSTAL AF OAC use: ICM 10% vs. Control 4.6% Stroke/TIA 5.2% Stroke/TIA 8.6% Sanna T. N Engl J Med. 2014;370:
23 In Summary The rationale for screening is sound Implementation has challenges Sensitivity & specificity in practice are not optimal 23
24 In Summary Systematic/population screening is far more costly, with a marginal increase in yield Whether or not screening improves outcomes remains unproven Opportunistic (NOT population) screening is best practice 24
25 Thank you 25
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