title: Screening for atrial fibrillation in general practice: a national, cross-sectional study of an innovative technology. Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial A randomised controlled trial and cost effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in the over 65s: (SAFE) [ISRCTN19633732] Left ventricular systolic dysfunction and atrial fibrillation in older people in the community--a need for screening? Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial Simplified electrocardiogram sampling maintains high diagnostic capability for atrial fibrillation: implications for opportunistic atrial fibrillation screening in primary care. Gender differences in utilization of colorectal cancer screening Rising Rates of Hospital Admissions for Atrial Fibrillation Stroke severity in atrial fibrillation. The Framingham Study. Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study). Self-detection of atrial fibrillation in an aged population: the LietoAF Study RISK OF STROKE IN NON-RHEUMATIC ATRIAL FIBRILLATION The additional value of routine electrocardiograms in cardiovascular risk management of older people A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Multifaceted implementation of stroke prevention guidelines in primary care: cluster-randomised evaluation of clinical and cost effectiveness Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Diagnostic yield of patient-activated loop recorders for detecting heart rhythm abnormalities in general practice: a randomised clinical trial. A comparison of rate control and rhythm control in patients with atrial fibrillation. Screening for atrial fibrillation in the community: a multicenter validation trial. Randomised trial of two approaches to screening for atrial fibrillation in UK general practice. Predicting the impact of the screening programme for colorectal cancer in the UK
abstract: BACKGROUND To test the use of three lead monitoring as a screening tool for  atrial fibrillation ( AF )  in general practice . AF is responsible for up to a quarter of all strokes and is often asymptomatic until a stroke occurs . METHODS 26 r and omly selected general practice s identified 80 r and omly selected patients aged 70 or older from their data base and excluded those known to have AF , those with clinical issues or who had not attended for three years . Up to 40 eligible patients / practice were invited to attend for screening . A 2min three-lead ECG was recorded and collected central ly for expert cardiology assessment . Risk factor data was gathered . OUTCOMES ( i ) point prevalence of AF , ( ii ) proportion of ECG tracings which were adequate for interpretation , ( iii ) uptake rate by patients and ( iv ) acceptability of the screening process to patients and staff ( reported separately ) . RESULTS Of 1447 current patients , 1003 were eligible for inclusion , 639 ( 64 % ) agreed to take part in screening and 566 ( 56 % ) completed screening . The point prevalence rate for AF was 10.3%-2.1 % new cases ( 12 of 566 who were screened ) and 9.5 % existing cases ( 137 of 1447 eligible patients ) . Only four of 570 ( 0.7 % ) screening visits did not record a usable ECG and 11 ( 2.6 % ) three lead ECGs required a clarifying 12 lead ECG . CONCLUSIONS Three lead screening for AF is feasible , effective and offers an alternative to pulse taking or 12 lead ECGs . The availability of this technology may facilitate more effective screening , leading to reduced stroke incidence Objectives To assess whether screening improves the detection of atrial fibrillation  ( cluster r and omisation ) and to compare systematic and opportunistic screening . Design Multicentred cluster r and omised controlled trial , with subsidiary trial embedded within the intervention arm . Setting 50 primary care centres in Engl and , with further individual r and omisation of patients in the intervention practice s. Participants 14 802 patients aged 65 or over in 25 intervention and 25 control practice s. Interventions Patients in intervention practice s were r and omly allocated to systematic screening ( invitation for electrocardiography ) or opportunistic screening ( pulse taking and invitation for electrocardiography if the pulse was irregular ) . Screening took place over 12 months in each practice from October 2001 to February 2003 . No active screening took place in control practice s. Main outcome measure Newly identified atrial fibrillation . Results The detection rate of new cases of atrial fibrillation was 1.63 % a year in the intervention practice s and 1.04 % in control practice s ( difference 0.59 % , 95 % confidence interval 0.20 % to 0.98 % ) . Systematic and opportunistic screening detected similar numbers of new cases ( 1.62 % v 1.64 % , difference 0.02 % , −0.5 % to 0.5 % ) . Conclusion Active screening for atrial fibrillation detects additional cases over current practice . The preferred method of screening in patients aged 65 or over in primary care is opportunistic pulse taking with follow-up electrocardiography . Trial registration Current Controlled Trials IS RCT N19633732 Background Atrial fibrillation ( AF ) has been recognised as an important independent risk factor for thromboembolic disease , particularly stroke for which it provides a five-fold increase in risk . This study aim ed to determine the baseline prevalence and the incidence of AF based on a variety of screening strategies and in doing so to evaluate the incremental cost-effectiveness of different screening strategies , including targeted or whole population screening , compared with routine clinical practice , for detection of AF in people aged 65 and over . The value of clinical assessment and echocardiography as additional methods of risk stratification for thromboembolic disease in patients with AF were also evaluated . Methods The study design was a multi-centre r and omised controlled trial with a study population of patients aged 65 and over from 50 General Practice s in the West Midl and s. These purpose fully selected general practice s were r and omly allocated to 25 intervention practice s and 25 control practice s. GPs and practice nurses within the intervention practice s received education on the importance of AF detection and ECG interpretation . Patients in the intervention practice s were r and omly allocated to systematic ( n = 5000 ) or opportunistic screening ( n = 5000 ) . Prospect i ve identification of pre-existing risk factors for AF within the screened population enabled comparison between high risk targeted screening and total population screening . AF detection rates in systematic ally screened and opportunistically screened population s in the intervention practice s were compared to AF detection rate in 5,000 patients in the control practice BACKGROUND Heart failure and stroke are major causes of morbidity and mortality in older people .  Angiotensin converting enzyme inhibitors improve symptoms and survival in left ventricular systolic dysfunction . Anticoagulants are effective in stroke prevention in atrial fibrillation with aspirin being a less effective alternative . OBJECTIVES To determine the prevalence of left ventricular systolic dysfunction , health services utilisation and prescribing of diuretics and angiotensin converting enzyme inhibitors in left ventricular systolic dysfunction , and the prevalence of atrial fibrillation and anti-platelet/thrombotic therapy in atrial fibrillation in older people in the community . METHODS 500 subjects were drawn by two-stage r and om sampling from 5,002 subjects aged 70 years and over living at home . Subjects were screened for atrial fibrillation and left ventricular systolic dysfunction using electrocardiography and echocardiography . RESULTS The population prevalence amongst older people of left ventricular systolic dysfunction was 9.8 % and of atrial fibrillation 7.8 % . More than two-thirds of those with left ventricular systolic dysfunction were not on angiotensin converting enzyme inhibitors . Of those in atrial fibrillation , 35 % were taking aspirin , 24 % were taking warfarin and 41 % were on neither aspirin nor warfarin . Nearly 90 % of older people in the community have had contact with their general practitioner over the past year , and over half of those with left ventricular systolic dysfunction have had contact with hospital-based services over the past 2 years . CONCLUSIONS Left ventricular systolic dysfunction is under-treated in older people in the community . Despite the high level of contact with hospital and community-based services , the majority of those with systolic left ventricular dysfunction are not on angiotensin converting enzyme inhibitors and a significant proportion of those in atrial fibrillation are not on any treatment for stroke prevention Objective To assess the accuracy of general practitioners , practice nurses , and interpretative software in the use of different types of electrocardiogram to diagnose atrial fibrillation . Design Prospect i ve comparison with reference st and ard of assessment of electrocardiograms by two independent specialists . Setting 49 general practice s in central Engl and . Participants 2595 patients aged 65 or over screened for atrial fibrillation as part of the screening for atrial fibrillation in the elderly ( SAFE ) study ; 49 general practitioners and 49 practice nurses . Interventions All electrocardiograms were read with the Biolog interpretative software , and a r and om sample of 12 lead , limb lead , and single lead thoracic placement electrocardiograms were assessed by general practitioners and practice nurses independently of each other and of the Biolog assessment . Main outcome measures Sensitivity , specificity , and positive and negative predictive values . Results General practitioners detected 79 out of 99 cases of atrial fibrillation on a 12 lead electrocardiogram ( sensitivity 80 % , 95 % confidence interval 71 % to 87 % ) and misinterpreted 114 out of 1355 cases of sinus rhythm as atrial fibrillation ( specificity 92 % , 90 % to 93 % ) . Practice nurses detected a similar proportion of cases of atrial fibrillation ( sensitivity 77 % , 67 % to 85 % ) , but had a lower specificity ( 85 % , 83 % to 87 % ) . The interpretative software was significantly more accurate , with a specificity of 99 % , but missed 36 of 215 cases of atrial fibrillation ( sensitivity 83 % ) . Combining general practitioners ' interpretation with the interpretative software led to a sensitivity of 92 % and a specificity of 91 % . Use of limb lead or single lead thoracic placement electrocardiograms result ed in some loss of specificity . Conclusions Many primary care professionals can not accurately detect atrial fibrillation on an electrocardiogram , and interpretative software is not sufficiently accurate to circumvent this problem , even when combined with interpretation by a general practitioner . Diagnosis of atrial fibrillation in the community needs to factor in the reading of electrocardiograms by appropriately trained people AIMS Atrial fibrillation ( AF ) is a major cause of morbidity , mortality , and health re source consumption . However , as many patients with chronic AF are asymptomatic , rapid , accurate opportunistic screening is needed in primary care to detect AF . Conventional electrocardiogram ( ECG ) technology is too clumsy and time consuming for mass opportunistic screening , thus technology that allows easy , rapid , yet accurate AF screening is required . To address this requirement a prototype h and -held electrode assembly was developed . We hypothesized that a 6-lead frontal-plane ECG acquired from this apparatus in a seated , clothed patient would be as accurate at detecting AF as conventional 12-lead ECG in the undressed , supine patient ( the ' gold st and ard ' ) . METHODS AND RESULTS Electrocardiograms were obtained from 78 patients with AF and 79 with sinus rhythm ( SR ) . All had a  conventional 12-lead ECG  , a 6-lead ECG from conventionally positioned limb electrodes , a supine 6-lead recording using the prototype recorder placed on the lower thorax/upper abdomen , and a 6-lead prototype recording in the seated patient , the latter with loosened clothing only . Electrocardiograms were r and omly and blindly assessed by two cardiologists for ( i ) diagnosis of AF vs. SR and ( ii ) tracing quality ( subjectively assessed as good , adequate , or bad ) . Compared with conventional 12-lead ECG recordings , all ' new ' recording methods performed satisfactorily with sensitivities ≥90 % ( 90 - 99 % ) , specificities ≥94 % ( 94 - 100 % ) , positive predictive values ≥94 % ( 94 - 100 % ) , negative predictive values ≥90 % ( 90 - 99 % ) , and accuracies ≥93 % ( 93 - 99 % ) . Tracing quality was higher in conventional 12-lead recordings ( 71 and 80 % were assessed as good by the two observers ) compared with conventional 6-lead ( 57 and 59 % ) , supine prototype ( 41 and 31 % ) , and sitting prototype ( 39 and 19 % ) . CONCLUSIONS Despite inferior electrocardiographic quality a 6-lead frontal plane ECG acquired by a simple prototype h and -held electrode assembly allowed reliable differentiation of AF from SR compared with st and ard 12-lead ECG Objectives : To assess the demographic and psychological mediators of gender differences in uptake of flexible sigmoidoscopy ( FS ) screening for colorectal cancer . Setting : A sub sample ( n=5462 ) from a large community trial of FS in the UK . Methods : Men and women r and omized to screening as part of the UK Flexible Sigmoidoscopy Trial were sent a postal question naire assessing  demographic characteristics and  attitudes  to screening six months before their screening appointment . Attendance at screening  was recorded by the screening centres . Results : More men than women  attended screening  ( 73 % versus 67 % ) . The higher male attendance was partially explained by their lower levels of socioeconomic deprivation , higher levels of marital status and lower perceived barriers to screening . Conclusions : Contrary to expectations , men weremore likely than women to attend FS screening .  This was partially explained by socioeconomic and attitudinal differences to screening , but additional research is needed to underst and the key aspects of FS screening that will maximize screening uptake in men and women Background : Atrial fibrillation is a common arrhythmia associated with excess morbidity and mortality . We studied temporal changes in hospital admission rates for atrial fibrillation using data from a prospect i ve population -based cohort study spanning 2 decades ( the Copenhagen City Heart Study ) . Methods : The study included baseline data collected in 1981 through 1983 on 10,955 persons age 40 to 79 years and baseline data collected in 1991 through 1994 on 7212 persons age 40 to 79 years . We used hospital diagnosis data from the Danish National Hospital Discharge Register to determine the rate of first hospital admission for atrial fibrillation during 7 years following each of the 2 baseline data collecting periods . Changes in admission rates were analyzed using Cox proportional hazard models . Results : During the 2 7-year periods , 379 subjects were admitted with a hospital diagnosis of atrial fibrillation . The rate of hospital admissions for atrial fibrillation increased among both men and women from the first to the second period ( relative risk = 1.6 ; 95 % confidence interval = 1.3–1.9 [ adjusted for age , sex , prior myocardial infa rct ion , arterial hypertension , diabetes mellitus , electrocardiographic left ventricular hypertrophy , decreased lung function , smoking , height , and weight ] ) . Conclusion : During the latest 10 to 20 years , there has been a 60 % increase in hospital admissions for atrial fibrillation independent of changes in known risk factors . This increase could result from changes in admission threshold or coding practice s , or it could reflect a genuine increase in the population incidence of atrial fibrillation BACKGROUND AND PURPOSE Stroke occurring with atrial fibrillation ( AF )  is more likely to be fatal or more severe than non-AF stroke based on clinical series , but data from prospect i ve epidemiological studies are sparse and inconsistent . METHODS Over 40-year follow-up of the original 5070 Framingham cohort , 501 initial ischemic strokes , including 103 with AF , were analyzed . Stroke severity was rated as none , mild , moderate , severe , or fatal . Since 1981 , functional status indicated by the Barthel index has been evaluated acutely and at 3 , 6 , and 12 months . Severity and functional status of AF strokes were compared with non-AF strokes using chi 2 test and Student 's t test . Thirty-day mortality was assessed by logistic regression analyses . RESULTS AF was associated with increased stroke severity ( P = .048 ) . Thirty-day mortality was greater in AF strokes than in non-AF strokes ( 25 % versus 14 % ) . The multivariate-adjusted odds ratio for 30-day mortality for AF subjects was 1.84 ( 95 % confidence interval , 1.04 to 3.27 ) . Since 1981 , follow-up was available for 150 initial ischemic strokes , including 30 with AF . Compared with the non-AF group , the AF group had poorer survival and more recurrences during 1 year of follow-up . The AF subjects had lower mean Barthel index scores acutely ( 29.6 versus 58.6 , P < .001 ) and at 3 months ( P = .005 ) , 6 months ( P = .003 ) , and 12 months ( P = .130 ) after stroke among survivors . CONCLUSIONS Ischemic stroke associated with AF was nearly twice as likely to be fatal as non-AF stroke . Recurrence was more frequent , and functional deficits were more likely to be severe among survivors . Since stroke is usually the initial manifestation of embolism in AF , prevention is critical to reducing disability and mortality Atrial  fibrillation ( AF ) is a common arrhythmia in elderly persons and a common cause of embolic stroke . Most studies of the prevalence and correlates of AF have used selected , hospital-based population s. The Cardiovascular Health Study is a population -based , longitudinal study of risk factors for coronary artery disease and stroke in 5,201 men and women aged > or = 65 years .  AF  was diagnosed in 4.8 % of women and in 6.2 % of men at the baseline examination , and prevalence was strongly associated with advanced age in women . Prevalence of AF  was 9.1 % in men and women with clinical cardiovascular disease , 4.6 % in patients with evidence of sub clinical but no clinical cardiovascular disease , and only 1.6 % in subjects with neither clinical nor sub clinical cardiovascular disease . A history of congestive heart failure , valvular heart disease and stroke , echocardiographic evidence of enlarged left atrial dimension , abnormal mitral or aortic valve function , treated systemic hypertension , and advanced age were independently associated with the prevalence of AF .  The low prevalence of AF in the absence of clinical and sub clinical cardiovascular disease calls into question the existence and clinical usefulness of the concept of so-called " lone atrial fibrillation " in the elderly Background Early detection of atrial fibrillation ( AF ) in older people is important because AF is often asymptomatic and its first manifestation may be a disabling stroke . The objective of the LietoAF Study is to assess the motivation and capability of older people to learn pulse palpation and continue regular pulse measurements , and whether this self- assessment is helpful in the detection of new AF . Design and method The LietoAF Study is an intervention study . A total of 205 people aged ≥75 years were r and omly selected to participate in the programme where a trained nurse gave individual education on pulse palpation . At 1 month , the eligible participants came to the first follow-up visit to assess the success of pulse self-monitoring . Results A total of 139 participants ( 68 % ) learned pulse palpation and performed regular measurements during the early follow-up period . The significant independent predictors for learning and motivation were high Mini-Mental State Examination score ( > 24 ) ( OR 7.5 , 95 % CI 1.5–37.3 , p = 0.014 ) , computer use at home ( OR 4.7 , 95 % CI 1.9–11.5 , p = 0.001 ) , independence at daily activities ( OR 4.2 , 95 % CI 1.4–13.6 , p = 0.013 ) and low heart rate ( OR 1.04 , 95 % CI 1.0–1.08 , p = 0.037 ) . Education did not cause extra visits to local healthcare centres and did not affect quality of life . Four participants observed a new asymptomatic AF during the 1-month follow-up . Conclusion Active older people are motivated and seem to learn pulse palpation . Our early experience suggests that simple nurse-based education is effective and useful in the early detection of asymptomatic AF Estimates of the risk of stroke for men with non-rheumatic atrial fibrillation were obtained from two large cohort studies --the Whitehall Study of London Civil Servants and the British  Regional Heart Study . The first cohort provided an estimated relative risk of stroke of 6.9 compared with controls . This increased risk confirms that of the other prospect i ve estimate , 5.6 , found in the Framingham study . In the second cohort only one of the men at risk had a stroke , and the risk estimate did not differ significantly from unity . The absolute rates of stroke in both cohorts were lower than those reported in the Framingham study , implying a lesser potential benefit from preventive measures . These lower rates should be considered in the planning of trials . The risk of stroke was significantly associated with raised systolic or diastolic blood pressure but not with age or coronary heart disease Objective . To evaluate whether routinely performed ECGs in older people from the general population have added value for cardiovascular risk management beyond the information that is already available from their medical records . Design . Observational , prospect i ve cohort study . Setting . General population . Subjects . A total of 566 participants aged 85 years ( 377 women , 189 men ) . Methods . Lifelong history of cardiovascular disease was assessed through medical records obtained from general practitioners . Baseline ECGs were evaluated for prior myocardial infa rct ion and atrial fibrillation . During a 5-year follow-up period , complete cardiovascular mortality and morbidity data were gathered . Results . During 5 years of follow-up , 262/566 ( 46 % ) participants died , of whom 102/262 ( 39 % ) died from cardiovascular disease . Participants with a history of cardiovascular disease at age 85 years ( 284/566 , 50 % ) had an increased cardiovascular mortality ( HR 2.7 , 95 % CI 1.8–4.1 ) and morbidity ( HR myocardial infa rct ion 2.1 , 95 % CI 1.3–3.6 ; HR stroke 2.7 , 95 % CI 1.6–4.9 ) compared with those without such a history . Participants with major ECG abnormalities ( 102/566 , 18 % ) had an increased cardiovascular mortality ( HR 1.8 , 95 % CI 1.1–2.8 ) , but no increase of cardiovascular morbidity compared with those without major ECG abnormalities . In both participants with and without a history of cardiovascular disease , the presence of major ECG abnormalities was not associated with increased cardiovascular mortality or morbidity . Conclusions . In older people from the general population , a history of cardiovascular disease is a strong predictor of cardiovascular mortality and morbidity . Although abnormal findings on routine ECGs predict cardiovascular mortality , they do not provide additional prognostic information beyond the information available from medical records . Therefore , when accurate medical records are available , programmatic ECG recording is not effective in older people OBJECTIVES To determine the most cost-effective method of screening for  atrial fibrillation ( AF ) in the population aged 65 years and over , as well as its prevalence and incidence in this age group . Also to evaluate the relative cost-effectiveness of different methods of recording and interpreting the electrocardiogram ( ECG ) within a screening programme . DESIGN Multicentred r and omised controlled trial . Purpose fully selected general practice s were r and omly allocated to 25 intervention practice s and 25 control practice s. SETTING Fifty primary care centres across the West Midl and s , UK . PARTICIPANTS Patients aged 65 years and over . INTERVENTIONS GPs and practice nurses in the intervention practice s received education on the importance of AF detection and ECG interpretation . Patients in the intervention practice s were r and omly allocated to systematic ( n = 5000 ) or opportunistic screening ( n = 5000 ) . Prospect i ve identification of pre-existing risk factors for AF within the screened population enabled comparison between targeted screening of people at higher risk of AF and total population screening . MAIN OUTCOME MEASURES AF detection rates in systematic ally screened and opportunistically screened population s in the intervention practice s were compared with AF detection rate in 5000 patients in the control practice s. The screening period was 12 months . RESULTS Baseline prevalence of AF was 7.2 % , with a higher prevalence in males ( 7.8 % ) and patients aged 75 years and over ( 10.3 % ) . The control population demonstrated higher baseline prevalence ( 7.9 % ) than either the systematic ( 6.9 % ) or opportunistic ( 6.9 % ) intervention population . In the control population 47 new cases were detected ( incidence 1.04 % per year ) . In the opportunistic arm 243 patients without a baseline diagnosis of AF were found to have an irregular pulse , with 177 having an ECG , yielding 31 new cases ( incidence 0.69 % per year ) . A further 44 cases were detected outside the screening programme ( overall incidence 1.64 % per year ) . In the systematic arm 2357 patients had an ECG yielding 52 new cases ( incidence 1.1 % per year ) . Of these , 31 were detected by targeted screening and a further 21 by total population screening . A further 22 cases were detected outside the screening programme ( overall incidence 1.62 % per year ) . In terms of ECG interpretation , computerised decision support software ( CDSS ) gave a sensitivity of 87.3 % , a specificity of 99.1 % and a positive predictive value ( PPV ) of 89.5 % compared with the gold st and ard ( cardiologist reporting ) . GPs and practice nurses performed less well . The only difference in performance between intervention population s and controls was that practice nurses from the control arm performed less well than with intervention practice nurses on interpretation of limb-lead ( PPV 38.8 % versus 20.8 % ) and single-lead ( PPV 37.7 % versus 24.0 % ) ECGs . The within-trial economic evaluation results showed the lowest incremental cost to be for the opportunistic arm , with an incremental cost-effectiveness ratio of 337 pounds Sterling for each additional case detected compared to the control arm . Opportunistic screening dominated both more intensive screening strategies . Model-based analyses showed small differences in cost and quality -adjusted life-years for different methods and intensities of screening , but annual opportunistic screening result ed in the lowest number of ischaemic strokes and greatest proportion of cases of AF diagnosed . Probabilistic sensitivity results indicated that there was a probability of approximately 60 % that screening from the age of 65 years was cost-effective in both men and women . CONCLUSIONS The results of the study indicated that in terms of a screening programme for atrial fibrillation in patients 65 and over , the only strategy that improved on routine practice was opportunistic screening , model-based analyses indicated that there was a probability of approximately 60 % of annual opportunistic screening being cost effective . It is suggested that the following topics are worthy of further investigation : the effect of the implementation of a screening programme for AF on the uptake and maintenance of anticoagulation in patients aged 65 years and over ; an evaluation of the role of CDSS in the diagnosis of cardiac arrythmias ; the best method for routinely detecting paroxysmal AF ; ways of improving healthcare professionals ' performance in ECG interpretation ; development of a robust economic model to incorporate data on new therapeutic agents for use as thromboprophylactic agents for patients with AF , and an evaluation of the relative risk of stroke for patients with incident as opposed to prevalent AF Objective : To evaluate clinical and cost effectiveness of implementing evidence -based guidelines for the prevention of stroke . Design : Cluster-r and omised trial Setting : Three primary care organisations in the North of Engl and covering a population of 400 000 . Participants : Seventy six primary care teams in four clusters : North , South & West , City I and City II . Intervention : Guidelines for the management of patients with atrial fibrillation and transient ischaemic attack ( TIA )  were developed and implemented using a multifaceted approach including evidence -based recommendations , audit and feedback , interactive educational sessions , patient prompts and outreach visits . Outcomes : Identification and appropriate treatment of patients with atrial fibrillation or TIA , and cost effectiveness . Results : Implementation led to 36 % increase ( 95 % CI 4 % to 78 % ) in diagnosis of atrial fibrillation , and improved treatment of TIA ( odds ratio of complying with guidelines 1.8 ; 95 % CI 1.1 to 2.8 ) . Combined analysis of atrial fibrillation and TIA estimates that compliance was significantly greater ( OR 1.46 95 % CI 1.10 to 1.94 ) in the condition for which practice s had received the implementation programme . The development and implementation of guidelines cost less than £ 1500 per practice . The estimated costs per quality -adjusted life year gained by patients with atrial fibrillation or TIA were both less than £ 2000 , very much less than the usual criterion for cost effectiveness . Conclusions : Implementation of evidence -based guidelines  improved the quality of primary care for atrial fibrillation and TIA . The intervention was feasible and very cost effective . Key components of the model include context ual analysis , strong professional support , clear recommendations based on robust evidence , simplicity of adoption , good communication and use of established networks and opinion leaders AIMS We aim ed to investigate the prevalence and incidence of atrial fibrillation ( AF )  in a large European population -based study . METHODS AND RESULTS The study is part of the Rotterdam study , a population -based prospect i ve cohort study among subjects aged 55 years and above . The prevalence at baseline was assessed in 6808 participants .  Incidence of AF was investigated during a mean follow-up period of 6.9 years in 6432 persons . We identified 376 prevalent and 437 incident cases . Overall prevalence was 5.5 % , rising from 0.7 % in the age group 55 - 59 years to 17.8 % in those aged 85 years and above . The overall incidence rate was 9.9/1000 person-years . The incidence rate in the age group 55 - 59 years was 1.1/1000 person-years , rose to 20.7/1000 person-years in the age group 80 - 84 years and stabilized in those aged 85 years and above . Prevalence and incidence were higher in men than in women . The lifetime risk to develop AF at the age of 55 years was 23.8 % in men and 22.2 % in women . CONCLUSION In this prospect i ve study in a European population , the prevalence and incidence of AF increased with age and were higher in men than in women . The high lifetime risk to develop AF was similar to North American epidemiological data BACKGROUND Because palpitations and light headedness often occur paroxysmally these complaints are difficult to diagnose . The hazards for a GP are too many diagnostic interventions for worried well and too few diagnostics for potentially life threatening complaints . OBJECTIVES Patient-activated memo event recorders have proved to be successful in diagnosing episodes of cardiac arrythmias in secondary care . We tested the diagnostic yield of these devices in general practice . METHODS A r and omized clinical trial in general practice . Consecutive patients with complaints of palpitations or light-headedness were r and omized to either usual care or usual care plus event-recorder . The main outcome was the difference in explained episodes . Secondary outcomes were the differences in the number and character of cardiac diagnoses and the feasibility of the event-recorder . RESULTS There were fewer patients without a diagnosis in the intervention group ( 17 % vs 38 % ; RR = 0.5 , 95 % CI 0.3 to 0.7 ) and more patients with a cardiac diagnosis ( 67 % vs. 27 % : RR 2.5 , CI 1.8 to 3,5 ) . More relevant cardiac arrhythmias were detected ( 22 % vs 7 % ) with event recording than with usual care ( RR 3.2 , 95 % CI 1.5 to 6.8 ) . CONCLUSION Patient-activated loop recorders are feasible and effective diagnostic tools in patients with palpitations or light-headedness in primary care . More research into patient characteristics and selection criteria is needed to fine-tune the use of these devices in primary care BACKGROUND There are two approaches to the treatment of atrial fibrillation : one is cardioversion and treatment with antiarrhythmic drugs to maintain sinus rhythm , and the other is the use of rate-controlling drugs , allowing atrial fibrillation to persist . In both approaches , the use of anticoagulant drugs is recommended . METHODS We conducted a r and omized , multicenter comparison of these two treatment strategies in patients with atrial fibrillation and a high risk of stroke or death . The primary end point was overall mortality . RESULTS A total of 4060 patients ( mean [ + /-SD ] age , 69.7+/-9.0 years ) were enrolled in the study ; 70.8 percent had a history of hypertension , and 38.2 percent had coronary artery disease . Of the 3311 patients with echocardiograms , the left atrium was enlarged in 64.7 percent and left ventricular function was depressed in 26.0 percent . There were 356 deaths among the patients assigned to rhythm-control therapy and 310 deaths among those assigned to rate-control therapy ( mortality at five years , 23.8 percent and 21.3 percent , respectively ; hazard ratio , 1.15 [ 95 percent confidence interval , 0.99 to 1.34 ] ; P=0.08 ) . More patients in the rhythm-control group than in the rate-control group were hospitalized , and there were more adverse drug effects in the rhythm-control group as well . In both groups , the majority of strokes occurred after warfarin had been stopped or when the international normalized ratio was subtherapeutic . CONCLUSIONS Management of atrial fibrillation with the rhythm-control strategy offers no survival advantage over the rate-control strategy , and there are potential advantages , such as a lower risk of adverse drug effects , with the rate-control strategy . Anticoagulation should be continued in this group of high-risk patients BACKGROUND Atrial fibrillation ( AF ) is an important public health problem . This arrhythmia is common and associated with a high risk of stroke . Further , appropriate interventions in AF can reduce the risk of stroke by approximately 68 % . Population studies show that a large group of patients have intermittent or chronic AF that remains unrecognized . If a simple screening test for this arrhythmia could be developed and vali date d , application of the technique across population s might identify AF patients for early treatment , potentially reducing the incidence of stroke . In this study , we sought to determine whether individuals taken from the general community could be taught to find and classify the pulse of another as very irregular , implying AF , or regular , implying normal sinus rhythm ( NSR ) . The aim was to establish that pulse examination for potential AF could be performed by individuals with sufficient sensitivity and specificity to be effectively used as a screening procedure for this medically important arrhythmia . METHODS We enrolled 178 subjects selected from the general community from four centers . Subjects received st and ardized education on the medical importance of AF and its signature , a very irregular pulse . A technique for palpating and characterizing the rhythm of the radial pulse was also taught . Without further coaching , subjects were then asked to find their pulse and then to find and classify the pulse of two models r and omly presented who may or may not have had AF . RESULTS Of the 178 subjects tested , 92 % were able to find their own pulse ; 17 ( 9.6 % ) were unable to find the pulse of one or both patient models and were , therefore , excluded from the study . Of the remaining 161 subjects , 76 % ( 122 of 161 ) correctly identified the pulse in an AF model , and 86 % ( 139 of 161 ) correctly identified the pulse in an NSR model . Results did not statistically differ as a function of age , educational status , or location . DISCUSSION This multicenter trial established that given minimal st and ardized instructions , subjects from the general community can reliably and consistently find both their pulse as well as the pulse of another and to differentiate a regular pulse from a very irregular pulse . If similar educational programs were widely applied across large population s , periodic screening for AF might lead to earlier diagnosis and appropriate treatment for patients who have this major risk factor for stroke . These screening programs should be focused on the population over the age of 55 where the risk of stroke in AF increases with each decade BACKGROUND Atrial fibrillation is a common and treatable cause of stroke that often remains unrecognised . Screening has been suggested but there is very little evidence concerning the uptake of screening in the elderly population at risk , nor of the optimal method of screening in a general practice setting AIM To compare the uptake and effectiveness of two methods of screening for atrial fibrillation in general practice -- systematic nurse-led screening and prompted opportunistic case finding . DESIGN OF STUDY R and omised controlled trial . SETTING Patients aged 65 to 100 years ( n = 3,001 ) from four general practice s within the MRC general practice framework . METHOD Each of the four study practice s were selected from one quartile , after ranking all framework practice s according to the small area st and ardised mortality ratio of the geographical area served . Patients were r and omised either to nurse-led screening or to prompted opportunistic casefinding . The proportion of patients assessed and the proportion found to have atrial fibrillation were compared . The sensitivity and specificity of clinical assessment of pulse are also reported . RESULTS Substantially more patients had their pulse assessed through systematic screening by invitation ( 1,099/1,499 [ 73 % ] ) than through opportunistic case finding ( 439/1,502 [ 29 % ] , difference = 44 % , 95 % confidence interval [ CI ] = 41 % to 47 % ) . Atrial fibrillation was detected in 67 ( 4.5 % ) and 19 ( 1.3 % ) patients respectively ( difference = 3.2 % , 95 % CI= 2.0 to 4.4 ) . Invitation to nurse-led screening achieved significantly higher assessment rates than case finding in all practice s ; however , the proportion of patients assessed in the case-finding arm varied markedly between practice s ( range = 8 % to 52 % ) . The number needed to screen to identify one additional patient with atrial fibrillation was 31 ( 95 % CI = 23 to 50 ) . The proportion of screened patients with atrial fibrillation receiving anticoagulation treatment was 25 % , although in the majority ( 53/65 [ 82 % ] ) atrial fibrillation had been previously recorded somewhere on their medical record . If the nurse used any irregularity of the pulse as the screening criterion , the sensitivity of screening was 91 % and the specificity was 74 % ; sensitivity fell to 54 % but specificity increased to 98 % if the criterion used was continuous irregularity . CONCLUSIONS Nurse-led screening for atrial fibrillation in UK general practice is both feasible and effective and will identify a substantial number of patients who could benefit from antithrombotic therapy . Although the majority of patients detected at first screening could be identified by careful scrutiny of medical records , review of record summaries was insufficient in the practice s involved in this study and screening may be a more cost-effective option Objectives Screening for colorectal cancer by biennial testing for faecal occult blood is being introduced in the UK from 2007 . We examine the likely impact of the programme , in terms of reduced mortality , lives saved and changes in incidence , over the next 20 years . Setting Projections of incidence and mortality of colorectal cancer in Engl and , and the policy that has been adopted for screening in Engl and ( biennial at ages 60–69 from 2007 , then 60–74 in 2010 ) . Methods The results are based on the output of a simulation model that has been used to examine cost-effectiveness of screening policy options , with two scenarios regarding compliance with screening ; both assume that 20 % of the population will never attend for screening , but attendance of those who do is modelled either as a r and om 60 % or 80 % , at each screening round . Results The decrease in mortality rates expected 20 years after introducing screening is 13–17 % in men and 12–15 % in women ( depending on the attendance levels ) . The model predicts an initial rise in incidence , followed ( after six to seven years ) by a fall , so that there is little net change in the number of cases detected over a 20-year period . Conclusion Percentage changes in mortality seem modest , but the projected saving in terms of numbers of lives is not negligible – 1800–2400 per year by 2025 in Engl and ( equivalent numbers are 2200–2700 in all over the UK ) . Newer screening modalities may improve on these projected results
target: Evidence suggests that systematic screening and opportunistic screening for AF increase the rate of detection of new cases compared with routine practice .
  Although these approaches have comparable effects on the overall AF diagnosis rate , the cost of systematic screening is significantly greater than the cost of opportunistic screening from the perspective of the health service provider .
background: BACKGROUND Atrial fibrillation ( AF ) , the most common arrhythmia in clinical practice , is a leading cause of morbidity and mortality .
  Screening for AF in asymptomatic patients has been proposed as a way of reducing the burden of the disease by detecting people who would benefit from prophylactic anticoagulation therapy before the onset of symptoms .
  However , for screening to be an effective intervention , it must improve the detection of AF and provide benefit for those detected earlier as a result of screening .
  OBJECTIVES This review aims to answer the following questions .Does systematic screening increase the detection of AF compared with routine practice ?
  Which combination of screening population , strategy and test is most effective for detecting AF compared with routine practice ?
  What safety issues and adverse events may be associated with individual screening programmes ?
  How acceptable is the intervention to the target population ?
  What costs are associated with systematic screening for AF ?