USPSTF Maintains AFib Screening Recommendation

Despite an extensive review of evidence and new clinical trials,¹ the US Preventive Services Task Force (USPSTF) reached a similar conclusion in the update to its 2018 screening recommendation for atrial fibrillation (AFib): There is insufficient evidence on both the harms and benefits of 1-time preventive screening for AFib for the USPSTF to issue a blanket recommendation for or against screening for adults 50 years and older without a diagnosis or symptoms of AFib, as well as no history of transient ischemic attack or stroke.²

Results were published online today in JAMA,² and this update replaces the 2018 screening recommendation.³

According to the USPSTF statement, “AFib is a major risk factor for ischemic stroke and is associated with a substantial increase in the risk of stroke. Approximately 20% of patients who have a stroke associated with AFib are first diagnosed with AFib at the time of the stroke or shortly thereafter.”²

The review commissioned by the USPSTF examined evidence published via PubMed, Cochrane Library, and trial registries published through October 5, 2020, and references, experts, and literature published through October 31, 2021, that encompassed 113,784 patients. Key questions on the harms and benefits of screening for AFib, detecting AFib, screening accuracy, and the benefits and harms of anticoagulation were investigated¹:

• Does screening for AFib with selected tests improve health outcomes (ie, reduce all-cause mortality, reduce morbidity or mortality from stroke, or improve quality of life) in asymptomatic older adults?
• Does systematic screening for AFib with selected tests identify older adults with previously undiagnosed AFib more effectively than usual care?
• What is the accuracy of selected screening tests for diagnosing AF in asymptomatic adults?
• What are the harms of screening for AFib with selected tests in older adults?
• What are the benefits of anticoagulation therapy on health outcomes in asymptomatic, screen-detected older adults with AFib?
• What are the harms of anticoagulation therapy in asymptomatic, screen-detected older adults with AFib?

Despite the review determining that unknown cases of AFib can be detected more often via screening, evidence remains limited on how health outcomes can be affected. In addition, there is still a risk of major bleeding from anticoagulation, and since the USPSTF’s 2018 screening recommendation, no new trials have investigated anticoagulation’s effect on screening-detected AFib.^1,2

According to the USPSTF, AFib is the most common cardiac arrhythmia, a major risk factor for ischemic stroke, and associated with increased stroke risk because it often remains undetected. Stroke can also be the first sign of AFib. Therefore, treatment typically encompasses symptom management and stroke prevention.² Anticoagulation is known to reduce risk of the latter, and the USPSTF’s review for this 2022 update investigated automated blood pressure cuffs, pulse oximeters, smartwatches and smartphone apps as additional screening methods.

One accompanying editorial to the USPSTF’s recommendation noted that the European Society of Cardiology reached a different conclusion in its most recent AFib guideline on diagnosis and management of the condition, released in 2020: AFib screening is recommended because of the potential for benefit from early detection and treatment in certain older individuals. This editorial noted that since 2018, just the STROKESTOP and LOOP trials have investigated AFib screening vs nonscreening in connection with clinical outcomes. The solution is simple: More data are needed for the USPSTF to come out officially for or against screening for AFib.⁴

A second editorial noted that although AFib screening can have important implications for public health, perhaps a blanket recommendation for persons above a certain age is not what’s needed. Instead, drilling down may be a better approach, including “assessing the burden of AFib, rather than the presence or absence of it”; utilizing deep learning algorithms “to identify and monitor individuals at higher risk for AFib”; and investigating specific behavior interventions detected through patient screening.⁵

References

1. Kahwati LC, Asher GN, Kadro ZO, et al. Screening for atrial fibrillation updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2022;327(4):368-383. doi:10.1001/jama.2021.21811

2. US Preventive Services Task Force. Screening for atrial fibrillation: US Preventive Services Task Force recommendation statement. JAMA. 2022;327(4):360-367. doi:10.1001/jama.2021.23732

3. USPSTF statement on screening for atrial fibrillation. News release. JAMA For the Media. January 25, 2022. Accessed January 25, 2022.https://media.jamanetwork.com/news-item/1-25-jama-uspstf-statement-on-screening-for-atrial-fibrillation/

4. Greenland P. Screening for atrial fibrillation—more data still needed. JAMA. 2022;327(4):329-330. doi:10.1001/jama.2021.23727

5. Kalscheur MM, Goldberger ZD. Screening for atrial fibrillation—refining the target. JAMA Netw Open. Published online January 25, 2022. doi:10.1001/jamanetworkopen.2021.39910