DOI: 10.1161/CIRCULATIONAHA.112.126656 1 Stepwise Screening of Atrial Fibrillation in a 75-Year Old Population: Implications for Stroke Prevention Running title: Engdahl et al.; Screening of Atrial Fibrillation Johan Engdahl, MD, PhD 1 ; Lisbeth Andersson, RN 1 ; Maria Mirskaya, RN 1 ; Mårten Rosenqvist, MD, PhD 2 1 Dept of Medicine, Hallands Hospital Halmstad, Halmstad, Sweden; 2 Dept of Clinical Science, Karolinska Institute, Danderyds Sjukhus, Stockholm, Sweden Address for Correspondence: Johan Engdahl, MD, PhD Department of Medicine Hallands Hospital Halmstad SE-301 85 Halmstad, Sweden Tel: +46-35-131000 Fax: +46-35-131559 E-mail: [email protected]Journal Subject Codes: [5] Arrhythmias, clinical electrophysiology, drugs; [8] Epidemiology; [193] Clinical studies; [121] Primary prevention; [64] Primary and Secondary Stroke Prevention; [70] Anticoagulants Mårten Rosenqvist, MD, PhD 2 1 De Dept pt o o of f f Me Me edi d ci ci ine ne n , Hallands Hospital Halmstad d, , , Ha H H lmstad, Sweden; ; 2 De D D pt of Clinical Science, Ka Ka Karo ro roli li lin ns nska ka k I I Ins ns nsti ti titu tu tute te e, , , Da Da D nd nd nder er eryd yds s s S S Sjuk k khu hu hus, s, s, S S Sto o oc ck ckho ho holm lm m, Sw S S ed ed den en en Add f C d by guest on February 11, 2018 http://circ.ahajournals.org/ Downloaded from
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DOI: 10.1161/CIRCULATIONAHA.112.126656
1
Stepwise Screening of Atrial Fibrillation in a 75-Year Old Population:
Implications for Stroke Prevention
Running title: Engdahl et al.; Screening of Atrial Fibrillation
Johan Engdahl, MD, PhD1; Lisbeth Andersson, RN1; Maria Mirskaya, RN1;
Mårten Rosenqvist, MD, PhD2
1Dept of Medicine, Hallands Hospital Halmstad, Halmstad, Sweden; 2Dept of Clinical Science,
Karolinska Institute, Danderyds Sjukhus, Stockholm, Sweden
history of AF and at least two risk factors according to CHADS2 were invited too aaa 222 wweeeeek k k
ecording period using a hand-held ECG asked to record 20 or 30 seconds twice daily and if
paalplppitititatatatiioionsnsns oooccurururrrered. 1330 inhabitants were invvvitititeddd of whom 84888 (644%)%)%) participated. Previously
uunddidiaga nosed sisilelelenttt AAAFFF wawawasss fofofouunund d ininn 100 ((1%%) aaamooonngg 8444888 ininndidiivividduduaalals s wwhw ooo rereecocoordrdededed 1112-2-2-leeadadad EEECCCG.
AmAmmononngg g 8181 pppataatieiennntsss wiwiiththh kknonownwnwn AAAF,F,F, 33555 (4(4(43%3%3%) )) wewewerere nootot ooonn n OAOAACC C trrreaeaeatmtmmeennt.t AAAmmomongngng 440033 ppperersssonnsns
with at least twtwwo o o riririsksksk fffacacctoorsrsrs ffforrr ssstrtrt okokoke,e,, wwwhohoho cccomomomplplpleteteteded ttthehehe hhhananand-d-d heeeldldld EEECGCGCG eeveveventntnt rrrecececoro ding, 30 kk
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Atrial fibrillation (AF) is the most common clinical arrhythmia with a prevalence steeply
increasing with age. The prevalence of AF is often reported to be 6-8% in patients aged 75
years1, 2. AF is also a frequent source of cardiac emboli and a common etiology of ischemic
stroke. The risk of ischemic stroke is increased in patients with AF3, 4. This risk can effectively
be reduced by oral anticoagulation treatment (OAC)5.
AF is sometimes symptomatic, but the correlation with symptoms is weak, thus AF can
be present with a lack of symptoms6-8. Often, an ischemic stroke is the first clinical sign of AF.
Ischemic stroke associated with AF is known to be particularly severe and more frequently fatal
than other ischemic strokes9, 10. AF is present in 25-30% of patients sustaining an acute ischemic
stroke9, 11, 12.
The aim of this study was to explore, by stepwise ECG screening, the prevalence of
previously not diagnosed asymptomatic AF, suitable for OAC treatment in a population aged 75-
76 years and to study to what extent they started OAC treatment.
Methods
Population
Halmstad is a municipality in the south-west part of Sweden with 92 000 inhabitants.
All individuals born in 1934 and 1935 were invited to participate by mail. If there was no
response in 4-6 weeks, a reminder was sent. If there was no response or an active declination, no
further contacts were made.
Index visit
At the index visit, all participants had to sign an informed consent and were asked to report their
han other ischemic strokes9, 10. AF is present in 25-30% of patients sustaining aannn acccututte e isisischchchememe ic
troke9, 11, 12.
ThThThee e aiaia m ofofof tthis study was to explore, byy sssteteppwise ECG sccrerer ennininngg,g, the prevalence of
prevvvioi usly nott dddiaii ggngnososededd aaasysysympmmptotoommamattiic AF,, ssuuitaabbllle fffororor OOACACAC ttrrreaatatmementntn in n aaa ppopopupuulalaatititioon aaagegeed d 775-
7666 yyyeaeaearsrsr aandndnd tto o sststuududy y toto wwhahatt t exexxtetetentntnt tthhehey yy stststaara teteted d d OAOAOACC C trtrreaeaeatmtmtmenenentt.t.
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medical history including presence of AF, antithrombotic treatment and thromboembolic risk
factors according to the CHADS2 risk classification13. If a patient reported a diagnosis of AF,
this had to be confirmed by ECG recordings in the medical records.
The accuracy of the self-reported medical history was confirmed only in patients with
AF. However, a random subset of 80 out of 727 patients with the questionnaire as the sole source
of medical history was cross-checked against medical records in hospital, in primary care and
against prescriptions. One of the 80 patients had erroneously omitted that he was treated for
hypertension, in the remaining 79 cases, medical history was reported correctly.
The index visit also included recording of a 12-lead ECG. The first 100 12-lead ECGs
were interpreted by a study nurse and a cardiologist; the following were interpreted by a study
nurse who consulted a cardiologist on demand. The ECG interpretations were also checked by
random samples viewed by a cardiologist. ECGs were interpreted only regarding rhythm and
rate. Patients who had atrio-ventricular block grade II or III or a heart rate below 40/min or
above 140/min were referred for further evaluation.
If the participant had a pacemaker or ICD implant, medical records were studied with
regard to the presence of atrial high rate episodes (mode switch) caused by AF. If present and
lasting more than 30 seconds, EGM recordings were studied.
If a 12-lead ECG revealed previously undiagnosed AF the patient was offered a work-up
consisting of blood pressure measurement, blood samples of fasting plasma glucose and thyroid
stimulating hormone at a study nurse visit and an echocardiogram at a cardiologist visit. Serum
glucose was not analysed in previously known individuals with diabetes. Patients with a
previously diagnosed AF without OAC treatment were offered this work-up if not previously
performed. After this work-up, the patient was recommended anticoagulation treatment unless
were interpreted by a study nurse and a cardiologist; the following were interpreetteted dd bybyy aa ssstututuddydy
nurse who consulted a cardiologist on demand. The ECG interpretations were also checked by
aandnddomomm ssamamamplpp ess vvviieiewed by a cardiologist. ECGGs ss wweere interpreteddd onlly y y rereregarding rhythm and
aateee. . Patients wwhhoh hhadadad aatrtrtrioioio-v-vveenentrtricicicuululaarr bbblocckk ggradddee II ooorrr IIIIIII ooror aa hheaeartrt rrrattte e bebebellolow w 404040/m/m/minin oor r
abbboovove ee 14140/0//mimiminn wewewerere rrefefferere rred dd fofoorrr fufufurrtrtheheer r evevevaaaluauauatitit onoon...
If thee ppparara titiicicicipapapantntnt hadadad aaa pppacacacememmakakkererer ooor r r ICICICDDD imimimplpp ananant,t,t, mmmededdicicicalal rrrecececororordsdsds wwwererere e e stststudududiei d with mm
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there were contraindications. OAC treatment was managed within routine health care and
initiated in our OAC clinic.
Extended ECG recording
Participants with at least one additional risk factor beside their age (i.e. CHADS2 –score >=2), no
history of AF and sinus rhythm on the 12-lead ECG at the index visit, were asked to make
additional ECG recordings. These were made by a handheld unit, recording ECG via lead I by
application of the users’ thumbs (Zenicor Medical Systems AB, Sweden. www.zenicor.se). Via
an in-built mobile phone, the ECG is transmitted to a website. The participant was instructed to
record 20 or 30 seconds of ECG twice daily during two weeks. The duration of the recording was
decided by a study nurse who judged the participants ability to handle the ECG recorder. All
handheld ECGs were interpreted by a cardiac research nurse and a cardiologist. AF was defined
as 30 seconds or at least two separate recordings with at least 10 seconds each of irregular
rhythm without visible p-waves. The Zenicor ECG system has been validated in previous
reports14, 15. Patients with AF were offered a work-up and offered treatment as described above.
In cases were interpretation of handheld ECGs was hampered by poor signal quality, the
participants were offered an additional 48-hour Holter recording. In participants who displayed
runs of suspected AF on event recording not qualifying according to the definition above,
another two-week period of event recording were offered according to the judgement of the
investigating cardiologist. A study flow chart is depicted in figure 1.
Medical records from inhabitants who did not participate in the screening process were
analysed with respect to AF diagnosis, presence of anticoagulation treatment and risk factors
according to CHADS2. Both hospital and primary care records were studied.
Ethics
decided by a study nurse who judged the participants ability to handle the ECG rereecooordrddereer.. AlAlAlll l
handheld ECGs were interpreted by a cardiac research nurse and a cardiologist. AF was defined
ass 33300 0 sesesecocoondndndsss orr aaattt lel ast two separate recordings s s wiwwith at least 10 sssece ononndsdsds each of irregular
hhhyttthmh withoutut vvvisssibbblelel ppp-w-wavavaveeses.. TTThhehe ZZZeennicooor ECGGG sysssteteem m hahaas s bebbeeenen vvaala iddatatededed iin n pppreevevioioioususus
eepopoportrtrtsss14,14 1515.. PaPPatitienenentsts wwwittth h AFAFF wwwererere ee oofoffefeferereedd d aaa wowoworkrkk-uuup p anannddd oooffefefererer d d trtrtreaeae tmtmtmenent tt asasas ddesesscrcrcribbededed aaboboovvee.
In casasesese wwwererere ee inini tett rprpprereretatatititionono ooof hahah ndndndheheheldldld EEECCCGsGsG wwwasasas hhhamammpepep rereed d d bybyby pppooooo r r sisisigngngnalalal qqquality, the
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The study was approved by the regional health research ethics board at Lund University and
conducted according to the declaration of Helsinki. Inhabitants who did not participate in the
screening procedure were informed via letter and newspaper advertising that we intended to
study their medical records in order to characterise this subgroup. They were given the
possibility to withdraw their participation also in this part of the study.
Statistical methods
Continuous variables are reported as mean and range. Selected proportions are reported with a
95% confidence interval. For continuous variables, student t-test was used. For proportions,
Fishers exact test was used. Two-tailed tests were applied. A p-value of < 0.05 was regarded as
significant. In the tables, p-values of < 0.05 are listed.
Results
Of 1330 inhabitants invited to participation, 848 (64%) attended the index screening visit. The
cardiac research nurse spent 30 minutes at index visit per patient including 12-lead ECG
registration and 40 minutes at handheld ECG recording including ECG interpretation per patient.
The cardiologist spent 5-10 minutes per patient for second opinion on handheld ECG recordings
and 60 minutes per visit including echocardiography among patients with newly diagnosed AF.
Characteristics including prevalence of AF among attending and not attending inhabitants
are described in Table. A previous diagnosis of AF was confirmed in 81/848 (9.6%, 95% CI 7.8-
11.7). In the group who did not attend the screening, the prevalence of AF was 39/352 (11.1%,
95% CI 8.2-14.8) (n.s.). Non-attendants had a higher prevalence of diabetes, heart failure and
previous stroke (Table).
Among the 81 patients who were previously diagnosed with AF in the screened group, 35
ignificant. In the tables, p-values of < 0.05 are listed.
ReResususultltltsss
OOOf 111333 0 inhabibitataanntts inininviviiteteteddd tototo ppararrtitit cicic ppaattiion,, 88448 (((644%)%)) aaatttteeendeded d dd thhhe e ininindedeex x sscscrrereenenininingg g viviv siiit.tt. TTThehee
caardrdrdiaiaiacc c rereseseearaarchch nuurursesee sspepep ntnt 333000 mimiminunnutetees s atatat iiindndndexexe vvvisissit pppererer pppatatieieientntt iincncncluludddinngng 1112-2--leleadadad EECCGCG
egistration aandndnd 4400 0 mimiminununutees s s atatat hhhaaandndn heheh lddd EEECGCGCG rrrecece ororordididingng iiincncncluluudididingngng EEECCCG G G ininnteteterprprereretatatatititiononon per patienttt.
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(43%) were not receiving anticoagulation treatment at study entry. The corresponding figure of
the non-screened group was 56% (n.s.). Of these 35 patients with previously known AF, 17/35
(52%) started anticoagulation treatment.
ECG recording – 12-lead ECG
Previously unknown AF was diagnosed in 10 patients (1.2%, 95% CI 0.5-1.9) with a 12-lead
ECG. The mean heart rate among these 10 patients was 83/min ranging from 64/min to 102/min.
Their mean CHADS2 –score was 1.8.
One participant of 848 was diagnosed with newly detected AV block III on 12-lead ECG
and received a pacemaker implant.
Extended handheld ECG recording
Among the 848 participants there were 419 (49%) with no previous AF, sinus rhythm on 12-lead
ECG at index visit and a CHADS2 –score of at least 2. Of these participants 16 declined further
participation or deceased, leaving 403 who underwent ECG event recording with the hand-held
ECG. These 403 participants in total recorded 12 380 ECG tracings lasting 20 or 30 seconds. The
mean number of recordings per patient was 31. 40 patients recorded less than 28 times but only
six patients recorded less than 20 times. All patients with ambulatory ECG recordings were
included in the final analysis. Ten of the 403 recordings had to be completed with a 48 hour-
Holter recording due to difficulties in interpreting the hand-held ECG recording and most often
with a suspicion of AF. Six of these ten recordings revealed paroxysmal AF. Due to short
episodes of irregular heart rhythm on hand-held ECG raising suspicion of AF but not fulfilling
our criteria, 4 participants undertook another period of two weeks ECG event recording. One of
these four recordings revealed paroxysmal AF.
Thus, 30/403 (7.4%, 95% CI 5.2-10.4) were diagnosed with AF previously unknown. The
Extended handheld ECG recording
Among the 848 participants there were 419 (49%) with no previous AF, sinus rhythm on 12-lead
ECCGGG atatat iiindndndexexex visissititit aand a CHADS2 –score of at lleaeae sstt 2. Of these papaarticcipippaanants 16 declined further
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mean numbeer r r ofofof rrrecececororordididingnggsss pepep r r papapatitiienee t t t wawawas s s 31311. 40404 pppatata ieeentntn sss rererecococordrdr ededd lllesesessss thththanana 222888 tititimememes but only
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hese 767 paartrtticicicipippananantsts wwwerreee exexexamamminini edede wwwititth hh exexextetetendnddededed hhananndhdhdheleleld d d ECECECG G G rererecococordrdrdinini g.g.g.
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unknown abnormal level of thyroid stimulating hormone.
Discussion
In this study, stepwise risk factor-stratified AF screening in a 75-76 year old population
identified a total prevalence of 14%, of which 62% had no OAC treatment. Among participants
who were examined with extended handheld ECG recording, 30/403 were diagnosed with
previously unknown paroxysmal AF. The amount of OAC treatment on AF indication more than
doubled among the screened participants. Screening for AF might become an effective method to
prevent stroke by initiation of OAC treatment.
Patient demographics
More than 60% of our community’s inhabitants aged 75 and 76 participated in the study. Since
our invitation process merely included an invitation by letter in combination with the fact that the
study was not accompanied by a media campaign, we are pleased with the participation. In an
AF prevalence study among 75-year old persons by Tveit et al., 82% of the population were
examined16. However, the Norwegian study used telephone reminders and even home visits for
ECG recording.
Interestingly, inhabitants not attending the AF screening programme had a higher burden
of cardiovascular risk factors than those attending since they had higher mean CHADS2-score,
affected by higher prevalence of diabetes, heart failure and stroke. There was no significant
difference in baseline AF prevalence among participants and non-participants.
ECG recording
A single 12-lead ECG-recording in a 75-year old population revealed only 1% of newly
diagnosed persistent or permanent AF, a figure also reported from Tveit et al16. Fitzmaurice et
Patient demographics
More than 60% of our community’s inhabitants aged 75 and 76 participated in the study. Since
ouur r r inininvivivitatatatititiononon prorooccecess merely included an invitaatititiononn by letter in cocoombmbininnatatatioi n with the fact that the
ttudddy y was not t acaccooompmppanannieieiedd d bybyby aa mmmeedediiaa ccammpapaaignn, wwwe arararee pppleeaasesedd wiwiththth thhehe ppparaartiticiciipapapatititionon. InInIn aaann n
AFAFF ppprererevavaleleencncncee ststtududdy y amamamonong 757575-y-y-yeaeaearr ololld d pepeperrrsononons s bybyby TTveveveititit eeet t alalal.,., 882%2%2% ooof tththe e popopopupupulalalattitionnn wwwerere ee
examined161616. HoHoHowewewevevever,r,r, tttheh NNNoroo wewewegigigianana ssstututudydydy uuuseseedd d tetetelelelephphhononone ee rereremimimindnddererersss ananand d d eveve enenen hhhomomome e visits for
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Intermittent ECG recording yielded 7% new AF diagnoses in our study, comparable to
the yield seen in extended ECG recordings in patients with ischemic stroke18, 19. This finding not
only underlines the importance of age in AF prevalence, but also that most patients with AF have
paroxysmal arrhythmia implicating that a single ECG recording with sinus rhythm has a low
negative predictive value in excluding a diagnosis of AF. Hence, among the total of 121 patients
with AF in this study, only 35 (29%) had persistent or permanent arrhythmia.
There are plenty of data on different methods of intermittent ECG-recording to detect
paroxysmal AF, most of it derives from studies on patients with cryptogenic ischemic stroke, on
patients who underwent AF ablation or from studies on antiarrhythmic drugs i.e. patient
populations with previously diagnosed AF or patients with generally high cardiovascular risk.
Studies on ambulant intermittent ECG recordings in the general population are scarce.
Continuous ECG monitoring, which would be regarded as “Gold standard” for ECG screening,
reveal previously undiagnosed paroxysmal AF in as much as 20-30% new AF diagnoses in
populations with high cardiovascular risk20, 21. The evidence for the elevated risk of ischemic
stroke in connection to brief AF episodes is mainly derived from device studies21, 22. The AF
episodes detected in this study are of larger recording proportion than the episodes detected in
device studies. Since the stroke risk is similar in paroxysmal and in permanent or persistent AF23,
24, we hypothesize that patients diagnosed with silent paroxysmal AF in this study has a stroke
risk similar to patients with clinical evident AF. Further long-term evaluation of our patients will
reveal the clinical course of their AF disease.
Technical development has provided several ways of ambulatory ECG recording. Short-
term Holter recordings of 24-48 h was previously the standard method but is hampered by low
patients who underwent AF ablation or from studies on antiarrhythmic drugs i.e.. ppatatatieientntnt
populations with previously diagnosed AF or patients with generally high cardiovascular risk.
Sttudududieieiesss ononn aaambmm ulululaanant t intermittent ECG recordingsgsgs innn the general popopopuulalaatititioon are scarce.
CCConntntinuous ECGCGG mmmononnitoororininingg,g, wwwhihiichchch wwowouuld bebebe regggaarrdeedd d asas ““GGoGoldldd sststananddad rrdrd”” fofofor r ECECCG G G scsccreeeeneninini ggg,
eevevevealalal ppprereviviviouoouslslyyy uununddiiagggnonoseeed d papaparororoxyxysmsmsmalalal AAAF F F inin aasss mmumuchchch aas s 20202 -3-3- 0%0%0% nnneweww AAAFFF didiagagagnnnossesess s inin
populations wiwiwiththh hhhigigigh h cacaardddioioiovavv scscscululu ararar rrisisiskkk202020, 212121.. ThThTheee evevevidddenenencecece fffororor tttheee eeelelelevavavateteted d d riririsksksk ooof f f isisi chemic
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oo dddetettecece titiononn ooof f sisiileleentnt ppparrroxoxysssmamamalll AFAFAF ininn cccomomompaaaririr sosoonn n tooo 224-4-4-hohhoururur HHHolollteteter r rrreccocordrdrdininnggg2727. HHHigghgh
diagnostic yyieieeldldld iisss deded momomonssstrtrtratatateddd bbby y MoMoMobibibilelele CaCaCardrdrdiaiaiac c OuOuO tptptpatatatieieentntnt TTTeleleemememetrtrtry y y (M(M(MCOCOCOT)T)T) aaandn
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disease or structural heart disease besides the more or less expected finding of enlarged left atria.
Since we only measured blood pressure at one visit, no patient was diagnosed with hypertension
in the work up.
Initiation of OAC
Patients with a newly diagnosed AF were more inclined to initiate OAC treatment than patients
with a known diagnosis of AF. Some of the patients with known AF without OAC treatment had
previously been treated with OAC in connection to a cardioversion, after which the OAC
treatment was withheld if sinus rhythm seemingly persisted. Patients with known AF without
symptoms seemed less declined to restart OAC treatment after its termination. The change in
2010 AF guidelines28 to recommend long-term OAC after cardioversion if there are
thromboembolic risk factors present was not always applied in patients treated according to
previous recommendations. Patients with newly diagnosed AF were on the other hand easily
motivated to commence OAC treatment, despite that most of them were without symptoms.
Undertreatment with OAC in patients with AF and thromboembolic risk factors is very
common. Among patients with known AF in our study, 43% were not receiving OAC at study
entry. According to nationwide Swedish inpatient-statistics, half of patients with AF are never
treated with OAC29. Similar figures are reported from Go et al.30 and Waldo et al31. A markedly
better guideline adherence with 85% of patients with AF and risk factors treated with OAC was
reported from Tveit et al16. Thus, the widespread OAC undertreatment in patients with AF
contributes to an unnecessary high stroke incidence.
AF prevalence
The baseline prevalence of AF the 75-year old population in this study (9.6%) is higher than
reported from most other studies. A prevalence of 6-8% is often reported in this age group 1, 2, 32,
2010 AF guidelines28 to recommend long-term OAC after cardioversion if theree aaareee ff
hromboembolic risk factors present was not always applied in patients treated according to
prrevevvioioiouusus rrrecececooommememenndations. Patients with newlyyy dddiaaagnosed AF weweerer oonn n tththe other hand easily
mmottitivav ted to ccomommmmemennccee OAOAOAC C C trtreaeaatmtmmeenntt,, dessppite ttthaat momomostst oooff f ththememem wwererre wiwithththoououtt ssysympmpm totommsms.
UnUndededertrtrereatatmmemennnt wwwitith h OAOAOACCC ininin pppatattieieientntnts wiwiw ththh AAAFFF aandndnd tthrhrromomombobooememembobobolilic c ririr sksks fffacacacttorrsrs iiis s veveeryyy
common. Ammmononong g g papapatitienenents wwwititith knknknowowwn n AFAFAF iiin n n ououourr r ststtudududy,, 4443%3%3% wwwererere nononott t rererecececeivivi innng g g OAOAOAC CC at study
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- ShShShororo t t t epepepisissodoo esess ooof f AFAFAF iiss s a cococ mmmmmmononon fffininindididingng ininin pppatata ieieientntn s sususufffffferererinining g g frfrromomom “crcrcrypyy togenic”
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For instance, 83% of invited 65-year old men accepted to participate in aortic abdominal
aneurysm screening in the Uppland region in Sweden 42.
Implications
Undiagnosed AF is often the aetiology behind “cryptogenic” stroke. It is a challenge of
considerable proportions to diagnose patients with silent AF and offer them OAC treatment.
Unfortunately, OAC is withheld among half of patients with already known AF and risk factors.
This study implies than patients with previously diagnosed and not yet diagnosed AF can get
better stroke prevention within a screening programme.
Conclusions
Stepwise risk factor-stratified AF screening in a 75-year old population yields a large share of
candidates for OAC treatment on AF indication. Persons not participating had more
cardiovascular risk factors than those participating. Patients with paroxysmal AF constitute the
majority of the AF population. Repeated handheld ECG recording detected new AF in 7% of
participants, and the total prevalence of AF was 14% in the population who participated in the
screening programme. Most patients with newly diagnosed AF were willing to commence OAC
treatment.
Acknowledgments: We thank Eva Mellberg for her work with administration of the study,
including patient invitation procedures. Contributors: JE and MR conceived the project and
designed it. JE, LA and MM made additional upgrades on the design and were responsible for
data collection. JE analysed the data. JE wrote the first draft of the paper. All authors assisted in
revising the paper and approved the final draft. JE is the guarantor.
Funding Sources: Grants were received from the Scientific Council of the Halland Region,
Conclusions
Stepwise risk factor-stratified AF screening in a 75-year old population yields a large share of
caandndndidididatatatesess fffoorr OOACACAC treatment on AF indication. PePePerrsons not partticici ipatattininingg had more
caardddioi vascularar rrisii kkk fafaf cctc oorors ss thththananan ththhososose e ppaparrticiipi aating.g. Patattieieentntsss wwiwiththh pppararoxoxxyyssmamaal l AFAF ccconononststtittuutute e thththeeh
mamaajojojoririritytyty ooff f thththee AFAFAF ppopoopuululatatioonn.n RRRepepepeeaeateteed dd hahahandndndheheh ldldd EEECGCGCG rrreececororrdidid nngng dddeteteeectteted d nenenew w w AFAFAF inn n 7%7%% ooof d
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and research grants from Sanofi Aventis, Merck Sharpe & Dome Boehringer Ingelheim.
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