Intended for healthcare professionals

Letters Screening for atrial fibrillation

Wilson and Jungner would not approve of screening for atrial fibrillation

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1416 (Published 24 April 2019) Cite this as: BMJ 2019;365:l1416

Re: Wilson and Jungner would not approve of screening for atrial fibrillation

Comment on Berge T. Wilson and Jungner would not approve of screening for atrial fibrillation. BMJ 2019;365:l1416 doi: 10.1136/bmj.l1416

We read the letter by Trygve Berge on screening for atrial fibrillation (AF) [1] with interest and would like to endorse the conclusions. The key issues are that we do not know whether or not screen-detected AF carries the same risk of stroke as disease that is clinically detected, and that the treatment, anticoagulation, is not without adverse effects. In their original 1986 report for the World Health Organisation [2], Wilson and Jungner specifically state that “In enthusiastically attacking disease at an early stage the Hippocratic principle, previously mentioned, of "primum non nocere" should not be neglected.” This has become modified into the more realistic principal that screening programmes should “do more good than harm at reasonable cost” [3] since it is now recognised that all screening does some harm.

Thus, unless we have robust evidence that finding and treating AF in an asymptomatic population reduces stoke rates and/or mortality without relying on lead time and volunteer bias, and can do so without conferring significant morbidity from anticoagulation, it would be difficult to recommend the introduction of a national screening programme for this condition. Such evidence can only be obtained by randomised trials where randomisation takes place at the point of invitation to screening. As outlined in Dr Berge’s letter, such studies are underway and will be given full attention by the UK National Screening Committee when they report.

References
1. Berge T. Wilson and Jungner would not approve of screening for atrial fibrillation. BMJ 2019;365:l1416 doi: 10.1136/bmj.l1416
2. Wilson JM, Jungner YG. Principles and practice of screening for disease. World Health Organisation, 1968
3. Raffle AE, Gray M. Screening: evidence and practice. 1st ed. Oxford University Press, 2007

Robert Steele, Independent Chair, UK National Screening Committee
r.j.c.steele@dundee.ac.uk

John Marshall, Evidence Lead, UK National Screening Committee
John.Marshall@phe.gov.uk

Anne Mackie, Director of Screening, UK National Screening Committee
Anne.Mackie@phe.gov.uk

Competing interests: No competing interests

01 May 2019
Robert Steele
Professor of Surgery and Independent Chair, UK National Screening Committee
John Marshall and Anne Mackie
University of Dundee
Ninewells Hospital, Dundee