Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial

This article is very interesting. The large number of study subjects
is the main strength of this interesting article. Atrial fibrillation is
responsible for approximately one in seven strokes in patients of all ages
and for one in four strokes in patients aged >80 years. Although the
average annual risk of stroke is approximately 5%, there is substantial
risk heterogeneity within the population of patients with atrial
fibrillation(1). In subjects from the original cohort of the Framingham
Heart Study, atrial fibrillation (AF) was associated with a 1.5- to 1.9-
fold mortality risk after adjustment for the preexisting cardiovascular
conditions with which AF was related. The decreased survival seen with AF
was present in men and women and across a wide range of ages. By pooled
logistic regression, after adjustment for age, hypertension, smoking,
diabetes, left ventricular hypertrophy, myocardial infarction, congestive
heart failure, valvular heart disease, and stroke or transient ischemic
attack, AF was associated with an odds ratio for death of 1.5 (95% CI, 1.2
-1.8) in men and 1.9 (95% CI, 1.5-2.2) in women (2). Preventive action is
mandatory. Find the AF in aging population, and treat the condition
properly.
Compared with aspirin, oral anticoagulant significantly decreases the
risk of all strokes, ischemic strokes, and cardiovascular events for
patients with non-valvular chronic or paroxysmal atrial fibrillation but
modestly increases the absolute risk of major bleeding. The balance of
benefits and risks varies by patient subgroupi. Treating 1,000 patients
for one year with oral anticoagulants rather than aspirin would prevent 23
ischaemic strokes while causing nine additional major bleeding
episodes(3).
The other review suggest that warfarin could prevent 30 strokes at the
expense of only 6 additional major bleeds. Aspirin could prevent 17
strokes, without increasing major hemorrhage. In direct comparison, there
was moderate evidence for fewer strokes among patients on warfarin than on
aspirin [aggregate OR=0.64 [95% CI 0.43-0.96]], with only suggestive
evidence for more major hemorrhage [OR =1.58 [95% CI 0.76-3.27]](4).
This article remind us to actively find the AF, and treat the AF properly,
especially in high risk group.

References
1. Anderson DC, Koller RL, Asinger RW, Bundlie SR, Pearce LA. Atrial
fibrillation and stroke: Epidemiology, pathophysiology, and management.
Neurologist 1998; 4(5):235-258.
2.Benjamin EJ, Wolf PA, D'Agostino RB, Silbershatz H, Kannel WB, Levy D.
Impact of atrial fibrillation on the risk of death: the Framingham Heart
Study. Circulation 1998; 98(10):946-952.
3. van Walraven C, Hart RG, Singer DE et al. Oral anticoagulants vs
aspirin in nonvalvular atrial fibrillation. An individual patient meta-
analysis. Journal of the American Medical Association 2002; 288: 2441-
2448
4. Segal JB, McNamara RL, Miller MR et al. Anticoagulants or antiplatelet
therapy for non-rheumatic atrial fibrillation and flutter. (Cochrane
Review). In: The Cochrane Library, Issue 1 2003. Oxford: Update Software.

Competing interests:
None declared