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USPSTF: Evidence insufficient on benefits, risks of ECG to diagnose AF
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The U.S. Preventive Services Task Force found inadequate evidence assessing the benefits and harms of screening for atrial fibrillation with ECG in patients aged 65 years and older with previously undiagnosed AF, according to a recommendation statement published in JAMA.
“The USPSTF found inadequate evidence to determine whether screening with ECG and subsequent treatment in asymptomatic adults is more effective than usual care,” the USPSTF wrote. “At the same time, the harms of diagnostic follow-up and treatment prompted by abnormal ECG results are well-established. Given these uncertainties, it is not possible to determine the net benefit of screening with ECG.”
Effect on clinical outcomes
There was inadequate evidence on the benefits of ECG screening for AF on clinical outcomes, although the evidence was adequate on the benefits of anticoagulant therapy, as it reduces the incidence of stroke in patients with symptomatic AF, the task force wrote.
Adequate evidence was found for small to moderate harms associated with ECG screening, including misdiagnosis, invasive procedures, additional testing and overtreatment. Abnormal results from ECG screening may also cause anxiety, the task force wrote.
Treating patients with AF with anticoagulant therapy is also linked to a small to moderate harm of an increased risk for major bleeding, according to the recommendation statement.
Further research is needed to compare screening with the usual care in patients with asymptomatic AF and to determine the best way to optimize ECG interpretation accuracy.
“Although the evidence review for this recommendation statement focused on screening with ECG, the effectiveness of newer technologies capable of assessing pulse and heart rhythm as potential screening strategies should be evaluated,” the USPSTF wrote. “In addition, as ECG and other technologies (eg, AliveCOR Kardia system [AliveCor Inc.], discussed in the context of the REHEARSE-AF trial) are used to record heart activity for longer periods and thus are able to detect shorter episodes of arrhythmia, understanding the stroke risk associated with brief episodes of subclinical atrial fibrillation and the potential benefit of anticoagulation therapy if risk is significant, is another important research need.”
Methods to diagnose AF
“Currently, the identification of atrial fibrillation by screening may be the best available method to diagnose an underlying atrial myopathy that predisposes to [AF-associated cardioembolic stroke], but it is likely neither sensitive nor specific enough as an isolated approach,” Jeffrey J. Goldberger, MD, MBA, chief of the cardiovascular division at University of Miami Miller School of Medicine, and Raul Mitrani, MD, associate professor at University of Miami Miller School of Medicine, wrote in a related editorial in JAMA. “Improved algorithms that address the important interactions among risk scores, extent of atrial myopathy and atrial fibrillation burden are required to optimize treatment. Perhaps most importantly, better diagnostics for atrial myopathy are needed to address this significant public health problem.”
“It is clear that we need a widespread, cost-effective approach to AF screening not only in the United States, but around the world,” Rod Passman, MD, MSCE, professor of medicine (cardiology) and preventive medicine at Northwestern University Feinberg School of Medicine, and Jonathan Piccini, MD, MHSc, associate professor of medicine at Duke University Medical Center and Duke Clinical Research Institute, wrote in a related editorial in JAMA Cardiology. “Given the aging of the world population and the growing prevalence of comorbidities that contribute to AF, including obesity and physical inactivity, the predicted epidemic of AF is already upon us. The costs of unrecognized — and thereby untreated — AF are too great from a personal and societal perspective to make this anything short of a major public health issue. How best to address this issue remains to be seen. Ongoing and future studies should provide the guidance we need.” – by Darlene Dobkowski
References:
Goldberger JJ, et al. JAMA. 2018;doi:10.1001.jama.2018.9185.
Jonas DE, et al. JAMA. 2018;doi:10.1001/jama.2018.4190.
Passman R, et al. JAMA Cardiol. 2018;doi:10.1001/jamacardio.2018.2200.
US Preventive Services Task Force. JAMA. 2018;doi:10.1001/jama.2018.10321.
Disclosures: The authors report receiving travel reimbursement and an honorarium for participating in USPSTF meetings. Goldberger reports holding a patient pending for a system and method used to map and quantify in vivo blood flow stasis. Mitrani reports no relevant financial disclosures. Passman reports he received grants from Kardia and Medtronic and personal fees from Medtronic. Piccini reports he received consultant fees from Allergan, Bayer, Johnson & Johnson, Medtronic, Philips and Sanofi and grants to his institution from Abbott Laboratories, ARCA Biopharma, Boston Scientific, Gilead Sciences, Janssen Pharmaceuticals and Verily Life Sciences.
Perspective
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Steven Steinhubl, MD
The USPSTF report is evidence based, so I cannot disagree with the recommendations, although I feel they are overly strict, but also the timing is just unfortunate. It was written right before we published mSToPS (Steinhubl SR, et al. JAMA. 2018;doi:10.1001/jama.2018.8102). The long-term follow-up results from STROKESTOP study will be coming out within the next 6 months. Both of those help answer some of the questions of the members’ concerns that they have about not really knowing the downside of ECG screening, which is a legitimate question to ask.
This recommendation does not have too many implications on clinical practice because it is saying to continue your clinical practice as it is. What will change clinical practice is if we have well-done, large-scale, pragmatic trials that answer the questions that they have.
For our mSToPS trial, people appropriately asked, “Now what? So what? What does this mean?” We need clinical outcome data. The STROKESTOP study will be able to provide some of that, as they will have 5-year follow-up results coming out in the next 6 months. In our study, we have utilization data coming out that will very much be able to answer the question of what is the “collateral damage” that comes from screening a large group of individuals with ECGs?
When I was in training in cardiology, if you found AF, you knew it and you had to consider anticoagulation, yes or no. Now that we’re getting much better at finding AF, the question that people are appropriately asking is, “Does everyone who has AF even in short episodes need to be anticoagulated?” That is one question we need to answer.
Furthermore, we have to start expanding what our questions are. Even in our population where the average age is 73 years, 7% of the individuals were found to have AF. It is not a normal finding, as some people try to oversimplify and say, “If you look for AF, you’ll find it.” That’s not true. We know there are things like weight loss, treating sleep apnea and potentially some medications that decrease the risk for developing AF.
We also need to figure out who benefits the most from anticoagulation therapy once AF is discovered, but we also need to say, “Once we find AF, besides anticoagulation, what else should we be doing to prevent the progression of AF or even to eliminate AF with lifestyle-changing things, non-ablation therapies and non-antiarrhythmic therapies?”
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