A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. A randomised controlled trial and cost effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in the over 65s: (SAFE) [ISRCTN19633732] Is screening for AF worthwhile? Stroke risk in a screened population from the SAFE study. Screening for asymptomatic atrial fibrillation while monitoring the blood pressure at home: trial of regular versus irregular pulse for prevention of stroke (TRIPPS 2.0). Assessment of Remote Heart Rhythm Sampling Using the AliveCor Heart Monitor to Screen for Atrial Fibrillation: The REHEARSE-AF Study Screening for atrial fibrillation in general practice: a national, cross-sectional study of an innovative technology. EARLY: a pilot study on early diagnosis of atrial fibrillation in a primary healthcare centre. Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL AF): design and rationale. Screening for atrial fibrillation in the community: a multicenter validation trial. The ADDITION-Cambridge trial protocol: a cluster – randomised controlled trial of screening for type 2 diabetes and intensive treatment for screen-detected patients Simplified electrocardiogram sampling maintains high diagnostic capability for atrial fibrillation: implications for opportunistic atrial fibrillation screening in primary care. Performance of a New Leadless Implantable Cardiac Monitor in Detecting and Quantifying Atrial Fibrillation Results of the XPECT Trial Randomised trial of two approaches to screening for atrial fibrillation in UK general practice. Uncovering Atrial Fibrillation Beyond Short-Term Monitoring in Cryptogenic Stroke Patients: Three-Year Results From the Cryptogenic Stroke and Underlying Atrial Fibrillation Trial Prevalence of atrial fibrillation in an urban population in India: the Nagpur pilot study A randomized clinical trial of early invasive intervention for atrial fibrillation (EARLY-AF) - methods and rationale. Patient knowledge and perceptions of atrial fibrillation and anticoagulant therapy: effects of an educational intervention programme. The West Birmingham Atrial Fibrillation Project.
OBJECTIVES To determine the most cost-effective method of screening for  atrial fibrillation ( AF ) in the population aged 65 years and over , as well as its prevalence and incidence in this age group . Also to evaluate the relative cost-effectiveness of different methods of recording and interpreting the electrocardiogram ( ECG ) within a screening programme . DESIGN Multicentred r and omised controlled trial . Purpose fully selected general practice s were r and omly allocated to 25 intervention practice s and 25 control practice s. SETTING Fifty primary care centres across the West Midl and s , UK . PARTICIPANTS Patients aged 65 years and over . INTERVENTIONS GPs and practice nurses in the intervention practice s received education on the importance of AF detection and ECG interpretation . Patients in the intervention practice s were r and omly allocated to systematic ( n = 5000 ) or opportunistic screening ( n = 5000 ) . Prospect i ve identification of pre-existing risk factors for AF within the screened population enabled comparison between targeted screening of people at higher risk of AF and total population screening . MAIN OUTCOME MEASURES AF detection rates in systematic ally screened and opportunistically screened population s in the intervention practice s were compared with AF detection rate in 5000 patients in the control practice s. The screening period was 12 months . RESULTS Baseline prevalence of AF was 7.2 % , with a higher prevalence in males ( 7.8 % ) and patients aged 75 years and over ( 10.3 % ) . The control population demonstrated higher baseline prevalence ( 7.9 % ) than either the systematic ( 6.9 % ) or opportunistic ( 6.9 % ) intervention population . In the control population 47 new cases were detected ( incidence 1.04 % per year ) . In the opportunistic arm 243 patients without a baseline diagnosis of AF were found to have an irregular pulse , with 177 having an ECG , yielding 31 new cases ( incidence 0.69 % per year ) . A further 44 cases were detected outside the screening programme ( overall incidence 1.64 % per year ) . In the systematic arm 2357 patients had an ECG yielding 52 new cases ( incidence 1.1 % per year ) . Of these , 31 were detected by targeted screening and a further 21 by total population screening . A further 22 cases were detected outside the screening programme ( overall incidence 1.62 % per year ) . In terms of ECG interpretation , computerised decision support software ( CDSS ) gave a sensitivity of 87.3 % , a specificity of 99.1 % and a positive predictive value ( PPV ) of 89.5 % compared with the gold st and ard ( cardiologist reporting ) . GPs and practice nurses performed less well . The only difference in performance between intervention population s and controls was that practice nurses from the control arm performed less well than with intervention practice nurses on interpretation of limb-lead ( PPV 38.8 % versus 20.8 % ) and single-lead ( PPV 37.7 % versus 24.0 % ) ECGs . The within-trial economic evaluation results showed the lowest incremental cost to be for the opportunistic arm , with an incremental cost-effectiveness ratio of 337 pounds Sterling for each additional case detected compared to the control arm . Opportunistic screening dominated both more intensive screening strategies . Model-based analyses showed small differences in cost and quality -adjusted life-years for different methods and intensities of screening , but annual opportunistic screening result ed in the lowest number of ischaemic strokes and greatest proportion of cases of AF diagnosed . Probabilistic sensitivity results indicated that there was a probability of approximately 60 % that screening from the age of 65 years was cost-effective in both men and women . CONCLUSIONS The results of the study indicated that in terms of a screening programme for atrial fibrillation in patients 65 and over , the only strategy that improved on routine practice was opportunistic screening , model-based analyses indicated that there was a probability of approximately 60 % of annual opportunistic screening being cost effective . It is suggested that the following topics are worthy of further investigation : the effect of the implementation of a screening programme for AF on the uptake and maintenance of anticoagulation in patients aged 65 years and over ; an evaluation of the role of CDSS in the diagnosis of cardiac arrythmias ; the best method for routinely detecting paroxysmal AF ; ways of improving healthcare professionals ' performance in ECG interpretation ; development of a robust economic model to incorporate data on new therapeutic agents for use as thromboprophylactic agents for patients with AF , and an evaluation of the relative risk of stroke for patients with incident as opposed to prevalent AF Background Atrial fibrillation ( AF ) has been recognised as an important independent risk factor for thromboembolic disease , particularly stroke for which it provides a five-fold increase in risk . This study aim ed to determine the baseline prevalence and the incidence of AF based on a variety of screening strategies and in doing so to evaluate the incremental cost-effectiveness of different screening strategies , including targeted or whole population screening , compared with routine clinical practice , for detection of AF in people aged 65 and over . The value of clinical assessment and echocardiography as additional methods of risk stratification for thromboembolic disease in patients with AF were also evaluated . Methods The study design was a multi-centre r and omised controlled trial with a study population of patients aged 65 and over from 50 General Practice s in the West Midl and s. These purpose fully selected general practice s were r and omly allocated to 25 intervention practice s and 25 control practice s. GPs and practice nurses within the intervention practice s received education on the importance of AF detection and ECG interpretation . Patients in the intervention practice s were r and omly allocated to systematic ( n = 5000 ) or opportunistic screening ( n = 5000 ) . Prospect i ve identification of pre-existing risk factors for AF within the screened population enabled comparison between high risk targeted screening and total population screening . AF detection rates in systematic ally screened and opportunistically screened population s in the intervention practice s were compared to AF detection rate in 5,000 patients in the control practice INTRODUCTION Atrial fibrillation ( AF ) is an important independent risk factor for stroke and oral anticoagulation therapy provides a highly effective treatment to reduce this risk . Active screening strategies improve detection of AF in comparison with routine care ; however , whether screen-detected patients have stroke risk profiles favouring anticoagulation is unclear . Using data derived from the screening for AF in the elderly ( SAFE ) study , the aim of this article was to determine if patients with AF detected via active screening  have stroke risk profiles that warrant prophylactic anticoagulation . METHODS Secondary analysis of data derived from 25 general practice s within which cohorts of 200 patients were r and omly allocated to opportunistic [ pulse and electrocardiogram ( ECG ) ] or systematic screening ( postal invitation for ECG ) .  Stroke risk assessment was undertaken using baseline data extracted from medical records and CHADS2 criteria . CHADS2 scores were compared between the screening groups . RESULTS One hundred and forty-nine new cases of AF were detected , 75 via opportunistic screening and 74 via systematic screening . CHADS2 scores were ≥1 in 83 % [ 95 % confidence interval ( CI ) 72.6 - 89.6 ] of patients detected via opportunistic screening and 78 % ( 95 % CI 67.7 - 86.2 ) detected via systematic screening . There were no significant differences in stroke risk profiles of patients detected via opportunistic and systematic screenings . CONCLUSION Stroke risk profiles of patients detected via opportunistic and systematic screenings were similar . Data derived from the SAFE study suggest that active screening for AF in patients aged ≥65 years in primary care is a useful screening programme with 78 - 83 % of patients identified eligible for anticoagulation treatment according to the CHADS2 criteria Asymptomatic atrial fibrillation ( AF ) is a common cause of strokes . Physician screening for AF has been recommended . Home screening for AF may increase the likelihood of detecting asymptomatic AF in patients at risk for stroke because of AF . The aim of this study was to assess the feasibility and accuracy of screening for AF when taking home blood pressure ( BP ) measurements using an automatic AF-detecting BP monitor .  Subjects aged > 64 years or those with hypertension , diabetes , congestive heart failure , or previous stroke were enrolled by their primary physicians and given the AF-BP monitor and an electrocardiographic event monitor to use at home for 30 days . The AF-BP monitor reading was compared with the electrocardiographic reading to calculate the sensitivity and specificity of the device for detecting AF . A total of 160 subjects were enrolled , with 10 withdrawing , 1 excluded , and 10 with no AF-BP monitor logs or electrocardiographic recordings . Of the 139 subjects included , 14 had known AF . There was a total of 3,316 days with AF-BP monitor readings and electrocardiographic readings . On the basis of the initial daily AF-BP monitor readings , the AF-BP monitor demonstrated sensitivity of 99.2 % and specificity of 92.9 % for detecting AF . Two subjects with no histories of AF had AF-BP monitor readings of AF that were confirmed by the electrocardiographic monitor . One of these subjects was started on warfarin . In conclusion , home screening for asymptomatic AF while taking BP measurements can be performed accurately . This can be used to detect new AF , allowing treatment with anticoagulation to reduce the future risk for stroke Background : Asymptomatic atrial fibrillation ( AF ) is increasingly common in the aging population and implicated in many ischemic strokes . Earlier identification of AF with appropriate anticoagulation may decrease stroke morbidity and mortality . Methods : We conducted a r and omized controlled trial of AF screening using an AliveCor Kardia monitor attached to a WiFi-enabled iPod to obtain ECGs ( iECGs ) in ambulatory patients . Patients ≥65 years of age with a CHADS-VASc score ≥2 free from AF were r and omized to the iECG arm or routine care ( RC ) . iECG participants acquired iECGs twice weekly over 12 months ( plus additional iECGs if symptomatic ) onto a secure study server with overread by an automated AF detection algorithm and by a cardiac physiologist and /or consultant cardiologist . Time to diagnosis of AF was the primary outcome measure . The overall cost of the devices , ECG interpretation , and patient management were captured and used to generate the cost per AF diagnosis in iECG patients . Clinical events and patient attitudes/experience were also evaluated . Results : We studied 1001 patients ( 500 iECG , 501 RC ) who were 72.6±5.4 years of age ; 534 were female . Mean CHADS-VASc score was 3.0 ( heart failure , 1.4 % ; hypertension , 54 % ; diabetes mellitus , 30 % ; prior stroke/transient ischemic attack , 6.5 % ; arterial disease , 15.9 % ; all CHADS-VASc risk factors were evenly distributed between groups ) . Nineteen patients in the iECG group were diagnosed with AF over the 12-month study period versus 5 in the RC arm ( hazard ratio , 3.9 ; 95 % confidence interval=1.4–10.4 ; P=0.007 ) at a cost per AF diagnosis of $ 10 780 ( £ 8255 ) . There was a similar number of stroke/transient ischemic attack/systemic embolic events ( 6 versus 10 , iECG versus RC ; hazard ratio=0.61 ; 95 % confidence interval=0.22–1.69 ; P=0.34 ) . The majority of iECG patients were satisfied with the device , finding it easy to use without restricting activities or causing anxiety . Conclusions : Screening with twice-weekly single-lead iECG with remote interpretation in ambulatory patients ≥65 years of age at increased risk of stroke is significantly more likely to identify incident AF than RC over a 12-month period . This approach is also highly acceptable to this group of patients , supporting further evaluation in an appropriately powered , event-driven clinical trial . Clinical Trial Registration : URL : https://www.is rct n.com . Unique identifier : IS RCT N10709813 BACKGROUND To test the use of three lead monitoring as a screening tool for  atrial fibrillation ( AF )  in general practice . AF is responsible for up to a quarter of all strokes and is often asymptomatic until a stroke occurs . METHODS 26 r and omly selected general practice s identified 80 r and omly selected patients aged 70 or older from their data base and excluded those known to have AF , those with clinical issues or who had not attended for three years . Up to 40 eligible patients / practice were invited to attend for screening . A 2min three-lead ECG was recorded and collected central ly for expert cardiology assessment . Risk factor data was gathered . OUTCOMES ( i ) point prevalence of AF , ( ii ) proportion of ECG tracings which were adequate for interpretation , ( iii ) uptake rate by patients and ( iv ) acceptability of the screening process to patients and staff ( reported separately ) . RESULTS Of 1447 current patients , 1003 were eligible for inclusion , 639 ( 64 % ) agreed to take part in screening and 566 ( 56 % ) completed screening . The point prevalence rate for AF was 10.3%-2.1 % new cases ( 12 of 566 who were screened ) and 9.5 % existing cases ( 137 of 1447 eligible patients ) . Only four of 570 ( 0.7 % ) screening visits did not record a usable ECG and 11 ( 2.6 % ) three lead ECGs required a clarifying 12 lead ECG . CONCLUSIONS Three lead screening for AF is feasible , effective and offers an alternative to pulse taking or 12 lead ECGs . The availability of this technology may facilitate more effective screening , leading to reduced stroke incidence AIM Atrial fibrillation ( AF ) is associated with high morbidity and mortality . Early diagnosis is likely to improve therapy and prognosis . The study objective was to evaluate the usefulness of a programme for early diagnosis of AF in patients from an urban primary care centre . METHODS AND RESULTS Participants were recruited from a r and omized sample of patients not diagnosed with AF but having relevant risk factors : age ≥ 65 years , ischaemic and /or valvular heart disease , congestive heart failure , hypertension , and /or diabetes . Patients were r and omly assigned to the intervention group ( IG ) or control group ( CG ) . The intervention included ( i ) initial visit with clinical history , electrocardiogram , and instruction about pulse palpation and warning signs and ( ii ) electrocardiogram every 6 months during a 2-year follow-up . The main endpoint of the study was the proportion of new cases diagnosed at 6 months . Secondary endpoints were number of new AF diagnoses and complications associated with the arrhythmia in both groups . A total of 928 patients were included ( 463 IG and 465 CG ) . At 6 months , AF was diagnosed in 8 IG patients and 1 CG patient ( 1.7 vs. 0.2 % , respectively , P = 0.018 ) . After 2 years of follow-up , 11 IG patients and 6 CG patients had newly diagnosed AF ( 2.5 vs. 1.3 % , respectively , P = 0.132 ) . Time to first diagnosis of AF was shorter in IG patients [ median ( inter-quartile range ) : 7 ( 192 ) days vs. 227 ( 188.5 ) days in CG , P = 0.029 ] . CONCLUSION The simple screening proposed could be useful for the early detection of AF in primary care Screening for  atrial fibrillation ( AF ) by assessing the pulse is recommended in high-risk patients . Some clinical trials demonstrated that the Microlife blood pressure monitor ( BPM ) with AF detection is more accurate than pulse palpation . This led to a change in practice guidelines in the United Kingdom where AF screening with the Microlife device is recommended instead of pulse palpation . Many BPMs have irregular heart beat detection , but they have not been shown to detect AF reliably . Recently , one study , in a highly select population , suggested that the Omron BPM with irregular heart beat detection has a higher sensitivity for AF than the Microlife BPM . We compared the Microlife and Omron BPMs to electrocardiographic readings for AF detection in general cardiology patients . Inclusion criteria were age≥50 years without a pacemaker or defibrillator . A total of 199 subjects were enrolled , 30 with AF . Each subject had a 12-lead electrocardiography , 1 Omron BPM reading , and 3 Microlife BPM readings as per device instructions . The Omron device had a sensitivity of 30 % ( 95 % confidence interval [ CI ] 15.4 % to 49.1 % ) with the sensitivity for the first Microlife reading of 97 % ( 95 % CI 81.4 % to 100 % ) and the Microlife readings using the majority rule ( AF positive if at least 2 of 3 individual readings were positive for AF ) of 100 % ( 95 % CI 85.9 % to 100 % ) . Specificity for the Omron device was 97 % ( 95 % CI 92.5 % to 99.2 % ) and for the first Microlife reading of 90 % ( 95 % CI 83.8 % to 94.2 % ) and for the majority rule Microlife device of 92 % ( 95 % CI 86.2 % to 95.7 % ; p<0.0001 ) . The specificity of both devices is acceptable , but only the Microlife BPM has a sensitivity value that is high enough to be used for AF screening in clinical practice BACKGROUND Patients with atrial fibrillation ( AF ) are at increased risk for ischemic stroke . In patients who have suffered a stroke , screening for AF is routinely performed only for a short period after the stroke as part of the evaluation for possible causes . If AF is detected after an ischemic stroke , oral anticoagulation therapy is recommended for secondary stroke prevention . In 25 % to 30 % of stroke patients , the stroke mechanism can not be determined ( cryptogenic stroke ) . The incidence of paroxysmal AF undetected by short-term monitoring in patients with cryptogenic stroke is unknown , but has important therapeutic implication s on patient care . The optimum monitoring duration and method of AF detection after stroke are unknown . The purpose of this study is to evaluate the incidence of AF and time to AF detection in patients with cryptogenic stroke using an insertable cardiac monitor . STUDY DESIGN The CRYSTAL AF trial is a r and omized prospect i ve study to evaluate a novel approach to long-term monitoring for AF detection in patients with cryptogenic stroke . Four hundred fifty cryptogenic stroke patients ( by definition , without a history of AF ) will be enrolled at approximately 50 sites in Europe , Canada , and the United States . Patients will be r and omized in a 1:1 fashion to st and ard arrhythmia monitoring ( control arm ) or implantation of the subcutaneous cardiac monitor ( Reveal XT ; Medtronic , Inc , Minneapolis , MN ) ( continuous monitoring arm ) . OUTCOMES The primary end point is time to detection of AF within 6 months after stroke . The clinical follow-up period will be at least 12 months . Study completion is expected at the end of 2012 BACKGROUND Atrial fibrillation ( AF ) is an important public health problem . This arrhythmia is common and associated with a high risk of stroke . Further , appropriate interventions in AF can reduce the risk of stroke by approximately 68 % . Population studies show that a large group of patients have intermittent or chronic AF that remains unrecognized . If a simple screening test for this arrhythmia could be developed and vali date d , application of the technique across population s might identify AF patients for early treatment , potentially reducing the incidence of stroke . In this study , we sought to determine whether individuals taken from the general community could be taught to find and classify the pulse of another as very irregular , implying AF , or regular , implying normal sinus rhythm ( NSR ) . The aim was to establish that pulse examination for potential AF could be performed by individuals with sufficient sensitivity and specificity to be effectively used as a screening procedure for this medically important arrhythmia . METHODS We enrolled 178 subjects selected from the general community from four centers . Subjects received st and ardized education on the medical importance of AF and its signature , a very irregular pulse . A technique for palpating and characterizing the rhythm of the radial pulse was also taught . Without further coaching , subjects were then asked to find their pulse and then to find and classify the pulse of two models r and omly presented who may or may not have had AF . RESULTS Of the 178 subjects tested , 92 % were able to find their own pulse ; 17 ( 9.6 % ) were unable to find the pulse of one or both patient models and were , therefore , excluded from the study . Of the remaining 161 subjects , 76 % ( 122 of 161 ) correctly identified the pulse in an AF model , and 86 % ( 139 of 161 ) correctly identified the pulse in an NSR model . Results did not statistically differ as a function of age , educational status , or location . DISCUSSION This multicenter trial established that given minimal st and ardized instructions , subjects from the general community can reliably and consistently find both their pulse as well as the pulse of another and to differentiate a regular pulse from a very irregular pulse . If similar educational programs were widely applied across large population s , periodic screening for AF might lead to earlier diagnosis and appropriate treatment for patients who have this major risk factor for stroke . These screening programs should be focused on the population over the age of 55 where the risk of stroke in AF increases with each decade Background The increasing prevalence of type 2 diabetes poses a major public health challenge . Population -based screening and early treatment for type 2 diabetes could reduce this growing burden . However , the benefits of such a strategy remain uncertain . Methods and design The ADDITION-Cambridge study aims to evaluate the effectiveness and cost-effectiveness of ( i ) a stepwise screening strategy for type 2 diabetes ; and ( ii ) intensive multifactorial treatment for people with screen-detected diabetes in primary care . 63 practice s in the East Anglia region participated . Three undertook the pilot study , 33 were allocated to three groups : no screening ( control ) , screening followed by intensive treatment ( IT ) and screening plus routine care ( RC ) in an unbalanced ( 1:3:3 ) r and omisation . The remaining 27 practice s were r and omly allocated to IT and RC . A risk score incorporating routine practice data was used to identify people aged 40–69 years at high-risk of undiagnosed diabetes . In the screening practice s , high-risk individuals were invited to take part in a stepwise screening programme . In the IT group , diabetes treatment is optimised through guidelines , target-led multifactorial treatment , audit , feedback , and academic detailing for practice teams , alongside provision of educational material s for newly diagnosed participants . Primary endpoints are modelled cardiovascular risk at one year , and cardiovascular mortality and morbidity at five years after diagnosis of diabetes . Secondary endpoints include all-cause mortality , development of renal and visual impairment , peripheral neuropathy , health service costs , self-reported quality of life , functional status and health utility . Impact of the screening programme at the population level is also assessed through measures of mortality , cardiovascular morbidity , health status and health service use among high-risk individuals . Discussion ADDITION-Cambridge is conducted in a defined high-risk group accessible through primary care . It addresses the feasibility of population -based screening for diabetes , as well as the benefits and costs of screening and intensive multifactorial treatment early in the disease trajectory . The intensive treatment algorithm is based on evidence from studies including individuals with clinical ly diagnosed diabetes and the education material s are informed by psychological theory . ADDITION-Cambridge will provide timely evidence concerning the benefits of early intensive treatment and will inform policy decisions concerning screening for type 2 diabetes . Trial registration Current Controlled trials IS RCT AIMS Atrial fibrillation ( AF ) is a major cause of morbidity , mortality , and health re source consumption . However , as many patients with chronic AF are asymptomatic , rapid , accurate opportunistic screening is needed in primary care to detect AF . Conventional electrocardiogram ( ECG ) technology is too clumsy and time consuming for mass opportunistic screening , thus technology that allows easy , rapid , yet accurate AF screening is required . To address this requirement a prototype h and -held electrode assembly was developed . We hypothesized that a 6-lead frontal-plane ECG acquired from this apparatus in a seated , clothed patient would be as accurate at detecting AF as conventional 12-lead ECG in the undressed , supine patient ( the ' gold st and ard ' ) . METHODS AND RESULTS Electrocardiograms were obtained from 78 patients with AF and 79 with sinus rhythm ( SR ) . All had a  conventional 12-lead ECG  , a 6-lead ECG from conventionally positioned limb electrodes , a supine 6-lead recording using the prototype recorder placed on the lower thorax/upper abdomen , and a 6-lead prototype recording in the seated patient , the latter with loosened clothing only . Electrocardiograms were r and omly and blindly assessed by two cardiologists for ( i ) diagnosis of AF vs. SR and ( ii ) tracing quality ( subjectively assessed as good , adequate , or bad ) . Compared with conventional 12-lead ECG recordings , all ' new ' recording methods performed satisfactorily with sensitivities ≥90 % ( 90 - 99 % ) , specificities ≥94 % ( 94 - 100 % ) , positive predictive values ≥94 % ( 94 - 100 % ) , negative predictive values ≥90 % ( 90 - 99 % ) , and accuracies ≥93 % ( 93 - 99 % ) . Tracing quality was higher in conventional 12-lead recordings ( 71 and 80 % were assessed as good by the two observers ) compared with conventional 6-lead ( 57 and 59 % ) , supine prototype ( 41 and 31 % ) , and sitting prototype ( 39 and 19 % ) . CONCLUSIONS Despite inferior electrocardiographic quality a 6-lead frontal plane ECG acquired by a simple prototype h and -held electrode assembly allowed reliable differentiation of AF from SR compared with st and ard 12-lead ECG Background —Current methods for detecting atrial fibrillation ( AF ) have limited diagnostic yield . Continuous monitoring with automatic arrhythmia detection and classification may improve detection of symptomatic and asymptomatic AF and subsequent patient treatment . The study purpose was to quantify the performance of the first implantable leadless cardiac monitor ( ICM ) with dedicated AF detection capabilities . Methods and Results — Patients ( n=247 ) with an implanted ICM ( Reveal XT , Medtronic Inc , Minneapolis , Minn ) who were likely to present with paroxysmal AF were selected . A special Holter device stored 46 hours of subcutaneously recorded ECG , ICM markers , and 2 surface ECG leads . The ICM  automatic arrhythmia classification was compared with the core laboratory classification of the surface ECG . Of the 206 analyzable Holter recordings collected , 76 ( 37 % ) contained at least 1 episode of core laboratory classified AF . The sensitivity , specificity , positive predictive value , and negative predictive value for identifying patients with any AF were 96.1 % , 85.4 % , 79.3 % , and 97.4 % , respectively . The AF burden measured with the ICM was very well correlated with the reference value derived from the Holter ( Pearson coefficient=0.97 ) . The overall accuracy of the ICM for detecting AF was 98.5 % . Conclusions —In this ICM validation study , the dedicated AF detection algorithm reliably detected the presence or absence of AF and the AF burden was accurately quantified . The ICM is a promising new diagnostic and monitoring tool for the clinician to treat AF patients independently of symptoms . Long-term studies are needed to evaluate the clinical benefits of the technology . Clinical Trial Registration — clinical trials.gov Identifier NCT00680927 BACKGROUND Atrial fibrillation is a common and treatable cause of stroke that often remains unrecognised . Screening has been suggested but there is very little evidence concerning the uptake of screening in the elderly population at risk , nor of the optimal method of screening in a general practice setting AIM To compare the uptake and effectiveness of two methods of screening for atrial fibrillation in general practice -- systematic nurse-led screening and prompted opportunistic case finding . DESIGN OF STUDY R and omised controlled trial . SETTING Patients aged 65 to 100 years ( n = 3,001 ) from four general practice s within the MRC general practice framework . METHOD Each of the four study practice s were selected from one quartile , after ranking all framework practice s according to the small area st and ardised mortality ratio of the geographical area served . Patients were r and omised either to nurse-led screening or to prompted opportunistic casefinding . The proportion of patients assessed and the proportion found to have atrial fibrillation were compared . The sensitivity and specificity of clinical assessment of pulse are also reported . RESULTS Substantially more patients had their pulse assessed through systematic screening by invitation ( 1,099/1,499 [ 73 % ] ) than through opportunistic case finding ( 439/1,502 [ 29 % ] , difference = 44 % , 95 % confidence interval [ CI ] = 41 % to 47 % ) . Atrial fibrillation was detected in 67 ( 4.5 % ) and 19 ( 1.3 % ) patients respectively ( difference = 3.2 % , 95 % CI= 2.0 to 4.4 ) . Invitation to nurse-led screening achieved significantly higher assessment rates than case finding in all practice s ; however , the proportion of patients assessed in the case-finding arm varied markedly between practice s ( range = 8 % to 52 % ) . The number needed to screen to identify one additional patient with atrial fibrillation was 31 ( 95 % CI = 23 to 50 ) . The proportion of screened patients with atrial fibrillation receiving anticoagulation treatment was 25 % , although in the majority ( 53/65 [ 82 % ] ) atrial fibrillation had been previously recorded somewhere on their medical record . If the nurse used any irregularity of the pulse as the screening criterion , the sensitivity of screening was 91 % and the specificity was 74 % ; sensitivity fell to 54 % but specificity increased to 98 % if the criterion used was continuous irregularity . CONCLUSIONS Nurse-led screening for atrial fibrillation in UK general practice is both feasible and effective and will identify a substantial number of patients who could benefit from antithrombotic therapy . Although the majority of patients detected at first screening could be identified by careful scrutiny of medical records , review of record summaries was insufficient in the practice s involved in this study and screening may be a more cost-effective option Background —Atrial fibrillation ( AF ) can be a cause of previously diagnosed cryptogenic stroke . However , AF can be paroxysmal and asymptomatic , thereby making detection with routine ECG methods difficult . Oral anticoagulation is highly effective in reducing recurrent stroke in patients with AF , but its initiation is dependent on the detection of AF . Cryptogenic Stroke and Underlying Atrial Fibrillation ( CRYSTAL AF ) is the first r and omized study to report the detection of AF in cryptogenic stroke patients using continuous long-term monitoring via insertable cardiac monitors ( ICM ) . Methods and Results — Patients with prior cryptogenic stroke were r and omized to control ( n=220 ) or ICM ( n=221 ) and followed for ⩽36 months . Cumulative AF detection rates in the ICM arm increased progressively during this period ( 3.7 % , 8.9 % , 12.4 % , and 30.0 % at 1 , 6 , 12 , and 36 months , respectively ) , but remained low in the control arm ( 3.0 % at 36 months ) . This result ed in oral anticoagulation prescription in 94.7 % of ICM patients with AF detected at 6 months , 96.6 % at 12 months , and 90.5 % at 36 months . Among ICM patients with AF detected , the median time to AF detection was 8.4 months , 81.0 % of first AF episodes were asymptomatic , and 94.9 % had at least 1 day with > 6 minutes of AF . Conclusions —Three-year monitoring by ICM in cryptogenic stroke patients demonstrated a significantly higher AF detection rate compared with routine care . Given the frequency of asymptomatic first episodes and the long median time to detection , these findings highlight the limitations of using traditional AF detection methods . The majority of patients with AF were prescribed oral anticoagulation therapy . Clinical Trial Registration — Clinical trials.gov ; Unique identifier : NCT00924638 Objectives Atrial fibrillation ( AF ) is the most common sustained arrhythmia encountered in clinical practice with major public health impact mainly due to the increased risk of stroke . The recent Global Burden of Disease Study reported a lack of prevalence data from India . Our goal was to conduct a pilot study to evaluate the feasibility of assessing AF prevalence and stroke prophylaxis in an urban Indian community . Methods A screening camp was conducted in Nagpur , India , that evaluated adults aged ≥18 years . We collected  demographics , recorded blood pressure , height , weight and the 12-lead electrocardiogram ( ECG ) .  The presence of diabetes and hypertension was recorded by self-reported history . Patients diagnosed with AF were evaluated further to assess aetiology and management . Results Of the total 4077 r and omly selected , community-dwelling adults studied , 0.196 % ( eight patients ) were found to have AF . Mean age of the population was 43.9±14.8 , and 44.5 % were female . The mean age of the patients with AF was 60.5±15.8 years ( five females )  . Rheumatic heart disease was found in five patients with AF . Three patients had history of stroke ( 37.5 % ) and one had peripheral arterial thrombosis . Three patients were on warfarin , but without routine international normalised ratio ( INR ) monitoring . One patient was on aspirin . Five patients were on β-blockers and one on both β-blocker and digoxin . Conclusions The prevalence of AF was low compared with other regions of the world and stroke prophylaxis was underused . A larger study is needed to confirm these findings . This study demonstrates that larger evaluations would be feasible using the community-based techniques employed here BACKGROUND The ideal management of patients with newly diagnosed symptomatic atrial fibrillation ( AF ) remains unknown . Current practice guidelines recommend a trial of antiarrhythmic drugs ( AAD ) prior to considering an invasive ablation procedure . However , earlier ablation offers an opportunity to halt the progressive patho-anatomical changes associated with AF , as well as impart other important clinical benefits . OBJECTIVE The aim of this study is to determine the optimal initial management strategy for patients with newly diagnosed , symptomatic atrial fibrillation . METHODS / DESIGN The EARLY-AF study ( Clinical Trials.govNCT02825979 ) is a prospect i ve , open label , multicenter , r and omized trial with a blinded assessment of outcomes . A total of 298 patients will be r and omized in a 1:1 fashion to first-line AAD therapy , or first-line cryoballoon-based pulmonary vein isolation .  Patients with symptomatic treatment naïve AF will be included . Arrhythmia outcomes will be assessed by implantable cardiac monitor ( ICM ) . The primary outcome is time to first recurrence of AF , atrial flutter , or atrial tachycardia ( AF/AFL/AT ) between days 91 and 365 following AAD initiation or AF ablation . Secondary outcomes include arrhythmia burden , quality of life , and healthcare utilization . DISCUSSION The EARLY-AF study is a r and omized trial design ed to evaluate the optimal first management approach for patients with AF . We hypothesize that catheter ablation will be superior to drug therapy in prevention of AF recurrence OBJECTIVE Previous research has demonstrated that patients with atrial fibrillation ( AF ) possess very little knowledge of their disease , the consequences of AF and the benefits /risks of anti-coagulant therapy . The aim of this pilot study was to examine patient 's knowledge and perceptions of AF and their anticoagulant treatment before and after a brief educational intervention . MATERIAL S AND METHODS Ninety-three patients ( 47 male ; mean ( S.D. ) age 67.3 ( 11.6 ) years ) completed the baseline interview to assess their knowledge and perceptions of AF . All patients were given an information booklet which explained what AF was , associated symptoms , the possible causes and consequences of AF , treatment options and their benefits /risks , what the INR is and what factors may effect it . The booklet was explained to each patient by the research er and given to the patient to take away for reference . Thirty-three ( 35.5 % ) patients ( 12 men ; mean ( S.D. ) age 68.0 ( 13.6 ) years ) completed the follow-up assessment to re-assess their knowledge and perceptions of AF . RESULTS Only 49 % of patients could name their cardiac condition at baseline , although the majority were aware that AF was an arrhythmia ( 80 % baseline vs. 91 % follow-up ) . Only about half the patients perceived AF as a serious condition or were aware that AF predisposes to thromboembolism at baseline . Following the educational intervention there was a non-significant increase in patient knowledge of the risks associated with AF . Of those who completed both question naires , 52 % were aware that anticoagulants prevented blood clots , which increased to 70 % post-intervention . However , few patients were aware of the benefit of stroke prevention associated with anticoagulants at baseline ( 21 % ) or after the educational intervention ( 27 % ) . The intervention had little effect on increasing awareness of the bleeding risks associated with anticoagulants , although three in five people appeared to appreciate these risks . However , the educational intervention significantly improved patient 's knowledge of the target INR range and factors that may affect INR levels ( p=0.001 and p=0.014 , respectively ) for those who completed both question naires . CONCLUSIONS Most patients with AF possess very limited knowledge about their cardiac condition , its consequences , and how anticoagulant treatment can benefit them . This pilot study has demonstrated that a brief educational intervention with an information booklet can help to somewhat improve their knowledge about anticoagulation therapy for AF
Systematic and opportunistic screening for AF increase the rate of detection of new cases compared with routine practice .
While both approaches have a comparable effect on the overall AF diagnosis rate , the cost of systematic screening is significantly more than that of opportunistic screening from the perspective of the health service provider .
BACKGROUND Atrial fibrillation ( AF ) is the most common arrhythmia in clinical practice and is a leading cause of morbidity and mortality .
Screening for AF in asymptomatic patients has been proposed as a way of reducing the burden of the disease by detecting people who would benefit from prophylactic anticoagulation therapy prior to the onset of symptoms .
However , for screening to be an effective intervention it must improve the detection of AF and provide benefit for those who are detected earlier as a result of screening .
OBJECTIVES The primary objective of this review was to examine whether screening programmes increase the detection of new cases of AF compared to routine practice .
The secondary objectives were to identify which combination of screening strategy and patient population is most effective , as well as assessing any safety issues associated with screening , its acceptability within the target population and the costs involved .