Global implementation and evaluation of atrial fibrillation screening in the past two decades - a narrative review

Advances in screening technology have been made in tandem with the aging population and increasing atrial fibrillation (AF) prevalence. While several randomized controlled trials demonstrate the efficacy of AF screening, less evidence has been synthesized addressing the implementation and evaluation of AF screening programs. We systematically searched the PubMed database from 1st January 2000 to 18th January 2024. The search terms included "atrial fibrillation" and "screening" and their synonyms. Articles that described screening implementation, including screening methods, were included. Editorial, commentary, engineering, and basic science articles were excluded. 1767 abstracts were screened, of which 138 full articles were reviewed, and 87 studies were included: 90% from high-income, 8% from upper-middle-income and 2% from lower-middle-income countries/ regions. The screening initiatives included general practice (n = 31), remote self-screening (n = 30), pharmacy (n = 11), community centers and villages (n = 10), hospital (n = 4), and nursing home (n = 1). Most studies used handheld ECG devices (n = 72, 83%), some used wearable devices (n = 13, 15%), and two (2%) used implantable cardiac devices. Comparator groups were described in 17% (15/87) studies: all 6 remote self-screening trials showed superior AF detection rates compared to usual care (these studies applied intermittent screening using handheld ECG devices over 2 weeks to 12 months or wearing ECG patches for continuous monitoring over 2-4 weeks), but 9 trials using systematic and opportunistic screening in primary care settings showed mixed results. Among 72 studies without comparator groups, 18 reported new AF detection rates below 1%, 48 reported 1-10%, 5 reported above 10%, and one reported an AF incidence rate of 2.25% patient-years (95% CI 2.03-2.48). Only 22% (19/87) of studies reported on the implementation evaluation (12 by surveys and 7 by interviews), surveying participant acceptability, usability, and satisfaction, and some studies in general practice and pharmacy interviewing participants and qualitatively evaluating the enablers and barriers to implementation. These studies reported barriers of lack of resources and referral pathways and enablers of having a designated staff member to lead implementation at point-of-care settings. AF screening implementation studies were mainly conducted in high-income countries/ regions. Detection rates were highest in older and higher risk groups, and if longer continuous ECG monitoring was used. Few studies reported details of the implementation of AF screening programs concerning cost, scalability, or comparative effectiveness of remote technology-driven screening approaches versus lower-tech approaches such as pulse palpation. Despite AF screening recommendations existing for some time, we seem to lack the data to effectively scale these initiatives.