Task Force finds insufficient evidence on screening for afib
The U.S. Preventive Services Task Force reviewed trials published since 2017 but did not deem them strong enough to show evidence of benefit or harm.
Current evidence is insufficient to assess the balance of benefits and harms of screening for atrial fibrillation, according to a new recommendation statement by the U.S. Preventive Services Task Force (USPSTF).
To update its 2018 recommendation, the Task Force conducted a systematic review of studies published since May 1, 2017, that evaluated the benefits and harms of screening for atrial fibrillation in older adults, the accuracy of screening tests and their effectiveness compared to usual care, and the benefits and harms of anticoagulant therapy for treating screening-detected atrial fibrillation in adults ages 50 years or older without a diagnosis or symptoms of atrial fibrillation and without a history of transient ischemic attack or stroke. Based on that review, the USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for atrial fibrillation (I statement).
The statement and the review were published Jan. 25 by JAMA. The Task Force's 2018 statement on this topic also found insufficient evidence to recommend for or against screening but looked only at electrocardiography (ECG), while the review supporting this statement examined studies of ECG and other types of screening tests.
Several editorials accompanied the recommendation statement and aimed to provide additional context. An accompanying editorial in JAMA noted that wearable monitoring devices could potentially provide more precise targeting of anticoagulant drugs while reducing stroke risk in the future. “The hope is that a future USPSTF report will eventually be able to either endorse—or advise clearly against—AF [atrial fibrillation] screening by ECG based on clear, objective evidence from well-conducted randomized trials,” the editorial stated.
In JAMA Cardiology, an editorial highlighted the benefits of diagnosing atrial fibrillation even if it is not treated. “For patients with no or few other stroke risk factors that would provide an indication for anticoagulation, screen-detected AF may serve as a wake-up call for the evaluation and treatment for upstream diseases such as sleep apnea or the adoption of lifestyle modifications that may reduce AF progression including weight loss, exercise, and alcohol reduction or abstinence,” the editorialists wrote.
A third editorial, published in JAMA Internal Medicine, noted the harms that may result from misdiagnosis and downstream cascades of care. “If you assume a 2% AF prevalence, even a device with 98% specificity will misdiagnose approximately 2000 individuals for every million screened. Additionally, ECG monitoring will detect non-AF arrhythmias such as bradycardia and premature ventricular contractions. The work-up of these can lead to anxiety, iatrogenic harm, and excess health care costs,” the editorialists wrote.
A fourth editorial, published in JAMA Network Open, noted that better ways are needed to translate evidence-based recommendations into patient-friendly language. It stated, “The USPSTF's new recommendation on AF screening presents valuable opportunities for discovery, including to enhance emerging AF risk estimation techniques and build on the evolving evidence base, to improve targeted screening and measure the impact of treatment.”