Consensus document: Screening and Prevention of Atrial Fibrillation Yong-Seog Oh, M.D.,Ph.D. Division of Cardiology, Department of Internal Medicine, Seoul St. Mary s Hospital, College of Medicine, The Catholic University of Korea
Conflict of interest : non-declared
References: - Screening for atrial fibrillation: a EHRA consensus document endorsed by the HRS, APHRS, SOLAECE. Europace 2017-2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016
Atrial fibrillation definitions - Overt AF: Episode of >30s of ECG documented absolutely irregular RR intervals with no distinct P wave, in the presence of typical symptoms related to AF - Asymptomatic (silent) AF: Episode of >30s of ECG documented absolutely irregular RR intervals with no distinct P wave, in the absence of symptoms. - AHRE (atrial high rate episode): Episodes of >5 min of AT/AF with an atrial rate >180 bpm, detected by CIED - Subclinical AF: Episode of AT/AF with duration between 5 min ~ 24 hour, detected in patients without clinical history or symptoms of AF
Rationale of AF screening AF is a major risk factor of thromboembolism and ischemic stroke, but 1/3 does not report symptom Risk of ischemic stroke seems to be similar or even higher in the asymptomatic AF 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. 2013;168:4744-9
Rationale of AF screening - Among patients presenting with stroke or TIA, new AF is diagnosed up to 37% in age <75 yrs with no history of cardiovascular disease. Proportion of new AF diagnoses at the time of ischemic stroke Stroke as the first manifestation of atrial fibrillation. Plos One 2017;11:e0168010
Expected advantages of detecting asymptomatic AF - Prevention of thromboembolic events and stroke by institution of oral anticoagulation in patients at risk - Prevention of subsequent onset of symptoms - Prevention and/or reversal of electrical/mechanical atrial remodeling - Prevention and/or reversal of tachycardiomyopathy at atrial and ventricular level - Prevention and/or reversal of AF-related hemodynamic derangements - Prevention of AF-related morbidity and reduction of AF-related hospitalizations - Reduction of AF-related mortality
Risk of AF - epidemiological considerations - Age and gender
- Other risk factors: - Caucasians - Obesity - Smoking - Obstructive sleep apnea - Comorbidities (COPD, heart failure, valvular heart disease, coronary artery disease, hypertension, uncontrolled HTN, hyperlipidemia, renal failure, prior CVA..) - CHA 2 DS 2 -Vasc score also correlates with AF occurrence in general population
Screening tools - Pulse palpation - Blood pressure automated measurement - ECG screening - Single-lead ECG handheld devices - Continuous cardiac rhythm monitoring devices: patches, belts, watches.. - Smartphone based monitoring
Screening and management strategy
Epidemiological considerations Test performance at detecting AF Prevalence and incidence of AF in target population Cost-effectiveness of AF screening
Efficacy of population screening strategies In patients 65 years, screening intervention improved AF diagnostic yield. No difference was observed between opportunistic and systematic screening method. Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over. BMJ 2007;335-383
AF detection rate in cryptogenic stroke patients AF detection in ILR arm increased progressively and was 8-fold higher at 36 months compared to the control arm. Uncovering atrial fibrillation beyond short-term monitoring in cryptogenic stroke patients. Circ Arrhythm Electrophysiol. 2016;9:e003333
AHRE (atrial high rate episode) in patients without AF AHRE >5min had 2.8 fold increased risk of CV mortality and 9 fold increase in risk of stroke mortality. Newly detected atrial high rate episodes predict long-term mortality outcomes in patients with permanent pacemakers. Heart Rhythm. 2014;11:2214-2221
Cost-effectiveness - Intermittent screening would save 44,000 EUR per 1000 simulated patients screened over 20 years. 1 - Screening for silent AF in patients with ischemic stroke resulted in a gain of 29 life-years, and cost savings of 55,400 EURO over a 20-year period. 2 1 Effectiveness of systematic screening for the detection of atrial fibrillation. Cochrane Database Syst Rev. 2013;4:CD009586 2 A cost-effectiveness analysis of screening for silent atrial fibrillation after ischaemic stroke. Europace 2015;17:207-214
Consensus statements - 1 1 ) Opportunistic screening for AF in the community by pulse taking or ECG strip recording is recommended in persons aged 65 years 2) Systematic ECG screening can be considered to detect AF in patients aged 75 years, or those at high stroke risk 3) ECG confirmation of AF is needed before considering the patient for anticoagulation therapy 4) Detection of AF is of crucial importance in stroke survivors and effects to screen for AF should include prolonged ECG monitoring, using external or implanted loop recorders
Consensus statements - 2 5) Regular interrogation of CIED, possibly using telesurveillance, should be considered for an earliest detection of subclinical AF and AHRE. 6) AHRE in combination with stroke risk factors is associated with an increased risk of stroke. 7) Intracardiac electrograms, rather than mode switching counters or marker channel analysis of AHRE episodes are recommended to confirm subclinical AF.
Prevention of AF - Modifiable risk factors - Hypertension - DM - Obesity - Smoking - Thyroid disease - Sleep disorder - Heart failure..
Lifestyle modification in patients at risk for AF - Following the DASH eating plan: - Low in saturated fat, trans fat and choleterol - Eat variety of whole grains fruits and vegetables - Cessation of smoking - Limit or avoid alcohol - Get regular physical activity - Maintain a healthy weight
Medical intervention 1) Use of RAS inhibitor in patients with CHF, and HTN combined with LVH, may prevent the risk of new-onset AF. 2) In diabetic patients, intensive glycemic control does not affect the rate of new-onset AF. Metformin seems to be associated with a decreased long-term risk of AF. 3) Obesity increases the risk for AF with a progressive increase according to BMI. Intensive weight reduction led to fewer AF recurrences in obese patients with AF. 4) In patients with obstructive sleep apnea (OSA), continuous positive airway pressure ventilation (CPPV) and risk factor reduction can reduce AF recurrence.
Conclusions 1. Opportunistic screening of AF is needed in all population of age 65 years. 2. Extended, long-term ECG monitoring is required for patients with cryptogenic stroke. 3. Appropriate AF screening is largely cost-beneficial. 4. Lifestyle modification and adequate medical treatment are important in patients at risk for AF development.
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