Opportunistic screening versus usual care for detection of atrial fibrillation in primary care: cluster randomised controlled trial [初级保健中机会性筛查与常规护理对房颤检测的比较：整群随机对照试验]

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BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3208 (Published 16 September 2020)
Cite this as: BMJ 2020;370:m3208

Authors
Steven B Uittenbogaart, Nicole Verbiest-van Gurp, Wim A M Lucassen, Bjorn Winkens, Mark Nielen, Petra M G Erkens, J André Knottnerus, Henk C P M van Weert, Henri E J H Stoffers

Abstract
Objective To investigate whether opportunistic screening in primary care increases the detection of atrial fibrillation compared with usual care.

Design Cluster randomised controlled trial.

Setting 47 intention-to-screen and 49 usual care primary care practices in the Netherlands, not blinded for allocation; the study was carried out from September 2015 to August 2018.

Participants In each practice, a fixed sample of 200 eligible patients, aged 65 or older, with no known history of atrial fibrillation in the electronic medical record system, were randomly selected. In the intention-to-screen group, 9218 patients eligible for screening were included, 55.0% women, mean age 75.2 years. In the usual care group, 9526 patients were eligible for screening, 54.3% women, mean age 75.0 years.

Interventions Opportunistic screening (that is, screening in patients visiting their general practice) consisted of three index tests: pulse palpation, electronic blood pressure measurement with an atrial fibrillation algorithm, and electrocardiography (ECG) with a handheld single lead electrocardiographic device. The reference standard was 12 lead ECG, performed in patients with at least one positive index test and in a sample of patients (10%) with three negative tests. If 12 lead ECG showed no atrial fibrillation, patients were invited for more screening by continuous monitoring with a Holter electrocardiograph for two weeks.

Main outcome measures Difference in the detection rate of newly diagnosed atrial fibrillation over one year in intention-to-screen versus usual care practices.

Results Follow-up was complete for 8874 patients in the intention-to-screen practices and for 9102 patients in the usual care practices. 144 (1.62%) new diagnoses of atrial fibrillation in the intention-to-screen group versus 139 (1.53%) in the usual care group were found (adjusted odds ratio 1.06 (95% confidence interval 0.84 to 1.35)). Of 9218 eligible patients in the intention-to-screen group, 4106 (44.5%) participated in the screening protocol. In these patients, 12 lead ECG detected newly diagnosed atrial fibrillation in 26 patients (0.63%). In the 266 patients who continued with Holter monitoring, four more diagnoses of atrial fibrillation were found.

Conclusions Opportunistic screening for atrial fibrillation in primary care patients, aged 65 and over, did not increase the detection rate of atrial fibrillation, which implies that opportunistic screening for atrial fibrillation is not useful in this setting.

Trial registration Netherlands Trial Register No NL4776 (old NTR4914).