Yonder: Screening for atrial fibrillation, antibiotics in care homes, hand, foot, and mouth disease, and asthma triple therapy

Alex Burrell

doi:10.3399/bjgp25X741273

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Asymptomatic atrial fibrillation patients, DOAC or don't?
Niall P. Fitzpatrick

Published on: 06 April 2025

Published on: (6 April 2025)
Page navigation anchor for Asymptomatic atrial fibrillation patients, DOAC or don't?
Asymptomatic atrial fibrillation patients, DOAC or don't?
Niall P. Fitzpatrick, GP, Eastham Group Practice. Wirral.
I read with interest this month’s Yonder article, which highlighted a recent study by Murphy et al. on loop-recorder screening for atrial fibrillation (AF).^1-2 They anticoagulated all patients found to have AF, but only followed them up for two weeks, prompting the question, whether diagnosing and anticoagulating asymptomatic patients truly provides a meaningful clinical benefit.

A recent Circulation meta-analysis,³ combined data from two randomised controlled trials (NOAH-AFNET 6⁴ and ARTESiA⁵). The results showed that direct oral anticoagulants (DOACs) modestly reduced stroke risk in asymptomatic, device-detected AF, yet increased bleeding rates. In these trials, AF was detected via pacemakers, implanted cardioverter defibrillators, or implantable cardiac monitors, and the patients were otherwise asymptomatic. The median CHA₂DS₂-VASc score in NOAH-AFNET 6 was 4 (IQR 3–5), while ARTESiA reported a mean of 3.9 (±1.1 SD).

By pooling more than 6,500 participants, the meta-analysis found that DOACs lowered the annual ischaemic stroke risk from 1.0% (aspirin or placebo) to 0.7%, translating to an absolute risk reduction [ARR] of 0.3% and a number needed to treat [NNT] of 333 per year. However, the annual major bleeding rate, defined according to ISTH criteria,⁶ increased from 1.0% to 1.7%, amounting to an absolute risk increase [ARI] of 0.7% (number needed to harm [NNH] of 143 per year)....
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I read with interest this month’s Yonder article, which highlighted a recent study by Murphy et al. on loop-recorder screening for atrial fibrillation (AF).^1-2 They anticoagulated all patients found to have AF, but only followed them up for two weeks, prompting the question, whether diagnosing and anticoagulating asymptomatic patients truly provides a meaningful clinical benefit.

A recent Circulation meta-analysis,³ combined data from two randomised controlled trials (NOAH-AFNET 6⁴ and ARTESiA⁵). The results showed that direct oral anticoagulants (DOACs) modestly reduced stroke risk in asymptomatic, device-detected AF, yet increased bleeding rates. In these trials, AF was detected via pacemakers, implanted cardioverter defibrillators, or implantable cardiac monitors, and the patients were otherwise asymptomatic. The median CHA₂DS₂-VASc score in NOAH-AFNET 6 was 4 (IQR 3–5), while ARTESiA reported a mean of 3.9 (±1.1 SD).

By pooling more than 6,500 participants, the meta-analysis found that DOACs lowered the annual ischaemic stroke risk from 1.0% (aspirin or placebo) to 0.7%, translating to an absolute risk reduction [ARR] of 0.3% and a number needed to treat [NNT] of 333 per year. However, the annual major bleeding rate, defined according to ISTH criteria,⁶ increased from 1.0% to 1.7%, amounting to an absolute risk increase [ARI] of 0.7% (number needed to harm [NNH] of 143 per year).

As the use of smartwatches grows, I believe we will see more asymptomatic AF diagnoses. A robust primary care RCT designed to assess the risks and benefits of anticoagulating this population would be invaluable. Until then, I consider the aforementioned trials the best evidence available for guiding shared decision making.

References

1. Burrell A. Yonder: Screening for atrial fibrillation, antibiotics in care homes, hand, foot, and mouth disease, and asthma triple therapy. Br J Gen Pract 2025; 75 (753): 180.
2. Murphy R, Waters R, Murphy A, et al. Risk-Based Screening of Atrial Fibrillation in General Practice (R-BEAT): A randomised Cross-over Trial. QJM. Published online January 9, 2025. doi:10.1093/qjmed/hcaf001.
3. McIntyre WF, Benz AP, Becher N, et al. Direct Oral Anticoagulants for Stroke Prevention in Patients With Device-Detected Atrial Fibrillation: A Study-Level Meta-Analysis of the NOAH-AFNET 6 and ARTESiA Trials. Circulation 2024;149(13):981-988. doi:10.1161/CIRCULATIONAHA.123.067512.
4. Kirchhof P, Toennis T, Goette A, et al. Anticoagulation with Edoxaban in Patients with Atrial High-Rate Episodes. N Engl J Med 2023;389(13):1167-1179. doi:10.1056/NEJMoa2303062.
5. Healey JS, Lopes RD, Granger CB, et al. Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation. N Engl J Med 2024;390(2):107-117. doi:10.1056/NEJMoa2310234.
6. Schulman S, Angerås U, Bergqvist D, et al. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients. J Thromb Haemost 2010;8(1):202-204. doi:10.1111/j.1538-7836.2009.03678.x.
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Competing Interests: None declared.

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