Intended for healthcare professionals

Rapid response to:

Head To Head

Should we screen for atrial fibrillation?

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l43 (Published 13 February 2019) Cite this as: BMJ 2019;364:l43

Rapid Response:

Is a screening programme the way forward for AF?

Dear Sirs,

The debate the authors have present in the article regarding the need for an AF screening programme is thought-provoking both from the point of view of disease burden, and the continuing appearance of screening in UK healthcare.

It seems an attractive prospect to implement a screening programme for this disease which is highly identifiable, treatable and as the authors have highlighted – is expanding rapidly with our ageing population. I am encouraged to read, through cohort study, that anticoagulation in so called screen-detected AF is associated with favourable outcomes in terms of survival and stroke risk[1]. However, surely these initial findings must be substantiated or challenged further in a randomised control trial before we seriously consider the role of a new screening programme.

I have my own concerns with AF screening. Firstly, would be the downstream cost (on finances and resources) of implementing the programme. If one is implemented, there will be a significant rise in patients requiring treatment by anticoagulation, be it warfarinisation or with newer, DOACs. In our current healthcare economy do we have the capacity to manage this batch of new patients i.e. anticoagulation clinic provision, ample trained clinicians for accurate diagnosis at screening, GPs monitoring more INRs, acute management of therapy-associated bleeding? However, if the benefit in terms of mortality reduction in heart failure, MI, ischaemic stroke and death from AF outweighs the resource burden, then perhaps the logistical challenge of screening is one we should accept. Nonetheless, this will be no small challenge given the estimated prevalence of AF in 2060 at more than 1 million people in the UK[2]. Another caveat to this is the interval between screening, additionally the authors’ note on paroxysmal AF being identified adds a source of possible unnecessary treatment and uncertain diagnosis.

The average UK citizen is subjected to an increasing variety of screening programmes throughout their lifetime, some more effective and cost-efficient than others. The NHS England abdominal aortic aneurysm (AAA) programme for example, was reviewed as continuing to be cost-effective[3] in 2016 and was previously observed to cost £5758 per year of life gained[4]. Although, with patients attending multiple different screening appointments, is uptake dwindling as they have to juggle more and more interaction with healthcare services on top of their own personal commitments? An experienced clinician can identify a possible AF simply through taking a patients pulse. The authors alluded to the rising use of self-monitoring devices and smart watches etc. in the role of identifying AF. Yet, is it time we handed some control to patients and encourage them to be more self-interested with their own health and fitness. How many patients/relatives/carers are able to monitor the pulse of themselves or another, a very simple skill? Public campaigns such as ‘Think FAST!’[5] have promoted awareness of the cardinal signs of a stroke, but to what degree are the public aware of the existence and simple detection of AF – one of the major causes of ischaemic stroke?

I welcome the idea of a screening programme for AF, provided it had the backing of more substantial, RCT based evidence. Ultimately, screening would see a rise in the number of people with an new diagnosis – do we have the resources to tackle that and are there more simple methods than a typical screening programme to identify atrial fibrillation and for patients to become more involved?

Yours sincerely,

Dr Jordan Wardrope,
MBChB, BMSc (Hons),
Junior Doctor in General Surgery

References:
1. Freedman B, Camm J, Calkins H, Healey JS et al. Screening for Atrial Fibrillation: a report of the AF-SCREEN International Collaboration. Circulation 2017; 135:1851-67
2. Lane DA, Skjøth F, Lip GYH, Larsen TB et al. Temporal trends in incidence, prevalence, and mortality of atrial fibrillation in primary care. J Am Heart Assoc 2017;6:e005155
3. Jacomelli J, Summers L, Stevenson A, Lees T et al. Impact of the first 5 years of a national abdominal aortic aneurysm screening programme. Br J Surg 2016;103(9):1125-31
4. Glover MJ, Kim LG, Sweeting MJ, Thompson SG et al. Cost-effectiveness of the National Health Service Abdominal Aortic Aneurysm Screening Programme in England. Br J Surg 2014;101(8):976-82
5. Dombrowski SU, Mackintosh JE, Sniehotta FF, Araujo-Soares V et al. The impact of the UK ‘Act FAST’ stroke awareness campaign: content analysis of patients, witness and primary care clinicians’ perceptions. BMC Public Health 2013;13(1):915

Competing interests: No competing interests

15 February 2019
Jordan Wardrope
Junior Doctor in General Surgery
NHS Lanarkshire