Updated USPSTF Guidelines for Screening for Atrial Fibrillation

Abstract

Five decades of research have illuminated the role of nonvalvular atrial fibrillation (AF) in the pathogenesis of stroke, heart failure, dementia, and premature death. Given the oftenasymptomatic nature of the arrhythmia and the clear benefit of premorbid interventions including anticoagulation for stroke prevention, it makes intuitive sense that screening for asymptomatic AF would affect outcomes. However, the evidence to support screening remains elusive and is complicated by questions as basic as who to screen, how best to screen, how much AF is actionable, and if we can do more good than harm by finding and treating AF early.It is in this context that the US Preventive Services Task Force (USPSTF) reports that "the current evidence is insufficient to assess the balance of benefits and harms of screening for AF" (I statement). 1 The evidence report and systematic review have also been updated. 2 This conclusion is not a recommendation against screening for AF but indicates that the evidence is insufficient to recommend either for or against screening. It mirrors the 2018 statement on the same topic, but several recent advances bolster both sides of the argument.The USPSTF statement does not currently support electrocardiogram (ECG) screening, but opportunistic screening via pulse palpation at the time of physical examination is recommended by multiple professional organizations in Europe, Canada, and Australia and by the World Heart Federation for those older than 65 years followed by an ECG if pulse irregularity is detected. [3][4][5] By contrast, the USPSTF considers opportunistic screening to be a facilitated case finding rather than actual screening and is considered to be part of routine or usual care.However, studies have not demonstrated a superiority of ECG compared with a thorough physical examination in the context of clinical trials although in usual clinical practice, the examination is infrequently performed, 6 is likely to detect more persistent AF, and can have high false-positive rates owing to ectopy and a high false-negative rate in older individuals owing to intrinsic or iatrogenic slowing of ventricular rates. Two randomized clinical trials of single-time opportunistic singlelead ECG screening in primary care did not find an increased rate of AF detection in the ECG screening practices compared with control practices, with the exception of those 85 years or older in the Screening for Atrial Fibrillation Among Older