Translation of a-t 2024; 55: 78

ESC guideline recommends screening for atrial fibrillation – despite new negative studies

In recent years, we have repeatedly addressed the issue as to whether screening for atrial fibrillation in asymptomatic individuals is beneficial in order to initiate therapy for a potentially improved prognosis and we reached a negative conclusion (a-t 2021; 52: 73-5, 2023; 54: 78-9, 2024; 55: 4-5). The recently updated European Society of Cardiology (ESC) guideline on atrial fibrillation has concretized its IIa recommendation on arrhythmia screening and advises non-invasive „prolonged“, i.e. repeated or continuous recordings in individuals aged 75 and over and 65 and over if another risk factor based on the CHA₂DS₂-VA score* is present.¹ Two randomised studies that fail to establish any clinical benefits of screening have been published concomitantly: In the US, 11,905 patients from the primary care sector, at least 70 years of age and not previously diagnosed with atrial fibrillation, took part in the GUARD-AF trial and were either fitted with a so-called patch monitor for the purpose of continuous single-channel electrocardiogram (ECG) recordings over a period of 14 days or received standard care.² The participants, with a median age of 75 (57% women) with a mean CHA₂DS₂-VASc score of 3.2, were followed up for 15.3 months. Atrial fibrillation based on ESC criteria was detected through screening in 5.0% and without screening in 3.3% of the participants. Oral anticoagulant therapy was initiated in 4.2% and 2.8%, respectively. 0.7% of the screened participants were admitted to hospital with stroke of any aetiology (primary endpoint) and 0.6% were of those who received standard care (hazard ratio [HR] 1.10; 95% confidence interval [CI] 0.69-1.75). Moreover, inpatient admissions for bleeding (1.0% vs. 1.1%; safety endpoint) and mortality rates (2.1% vs. 2.3%) did not differ significantly.² In the registry-based STROKESTOP-II study, 50% of all 27,789 75- to 76-year-old residents of a district in Stockholm received a written invitation to undergo screening for atrial fibrillation, while the other half served as controls.³ 49.2% accepted the invitation and initially underwent an NT-proBNP** assay. A 30-second, single-channel ECG was performed once in patients with values below 125 ng/l. For values of 125 ng/l and above (60% of the group), prolonged screening was carried out over two weeks, with four 30-second single-channel recordings daily. Patients with values in excess of 900 ng/l were referred directly to a cardiologist. The participants were 76.5 years old on average (53% women) with a mean CHA₂DS₂-VASc score of 3.5. Atrial fibrillation was detected for the first time through screening in 2.4% of subjects. After five years, it was detected with equal frequency in both groups (17.4% vs. 18.6%, not significant). 82% of cases were treated with oral anticoagulants in each case. Within a median period of 5.1 years, 0.99 cases of embolism or stroke of any aetiology occurred per 100 observation years in patients invited for screening (primary endpoint), compared to 1.03 in the controls (HR 0.96, 95% CI 0.86-1.06, p = 0.41). Furthermore, there was no significant difference in hospital admissions for haemorrhage (0.30 vs. 0.31) and overall mortality (3.06 vs. 2.98).³ These studies were also unable to prove a benefit of routine atrial fibrillation screening or of invitation for it even in elderly subjects. -Ed.

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