Atrial fibrillation: time for active case finding

Substantial evidence has now accrued to robustly support systematic case finding using pulse regularity checks in general practice to detect atrial fibrillation (AF) in people aged ≥65 years. Fay et al have summarised this evidence to make the case to detect an additional 10–15 cases of AF per 1000 people screened.¹ Cole et al have shown that such ascertainment in people aged ≥65 years by GPs is feasible in entire local CCG populations, with increases in AF register size of 5–10%.²

However, the National Screening Committee has so far remained doubtful about supporting a national screening programme for AF, and the US Preventive Services Task Force recently recommended against electrocardiographic screening for AF.³ An increasing number of methods to detect irregularity of heart beat — ranging from simple pulse checks every 5 years in primary care to continuous electronic monitoring detecting short-duration irregularities with less certain treatment benefits — have complicated the picture.⁴ Case finding in general practice using episodic pulse regularity checks is supported by a UK Health Technology Report concluding that: ‘Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography.’ ⁵

Current NICE guidance on the measurement of blood pressure also recommends pulse palpation to detect irregularity. However, despite the positive and cost-effective results of case finding shown in the randomised SAFE trial and observational studies in UK general practice,^2,6 some GPs and other commentators have remained doubtful about such simple methods for the systematic detection of AF.⁷ Large randomised controlled trials are the desirable gold standard for new cost-effective interventions for …