Simplified electrocardiogram sampling maintains high diagnostic capability for atrial fibrillation: implications for opportunistic atrial fibrillation screening in primary care. Performance of a New Leadless Implantable Cardiac Monitor in Detecting and Quantifying Atrial Fibrillation Results of the XPECT Trial Atrial fibrillation and paroxysmal atrial fibrillation detection in patients with acute ischemic stroke. Assessment of Remote Heart Rhythm Sampling Using the AliveCor Heart Monitor to Screen for Atrial Fibrillation: The REHEARSE-AF Study Screening for atrial fibrillation in general practice: a national, cross-sectional study of an innovative technology. Comparison of the Microlife blood pressure monitor with the Omron blood pressure monitor for detecting atrial fibrillation. 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. Screening for asymptomatic atrial fibrillation while monitoring the blood pressure at home: trial of regular versus irregular pulse for prevention of stroke (TRIPPS 2.0). Screening for atrial fibrillation in the community: a multicenter validation trial. Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device: implications for optimal patient care. 96 hours ECG monitoring for patients with ischemic cryptogenic stroke or transient ischaemic attack Magnesium infusion and postoperative atrial fibrillation: a randomized clinical trial. EARLY: a pilot study on early diagnosis of atrial fibrillation in a primary healthcare centre. Atrial fibrillation after coronary artery bypass surgery: P wave signal averaged ECG, clinical and angiographic variables in risk assessment. Frequent Atrial Premature Beats Predict Paroxysmal Atrial Fibrillation in Stroke Patients: An Opportunity for a New Diagnostic Strategy Diagnostic accuracy and yield of screening tests for atrial fibrillation in the family practice setting: a multicentre cohort study. Is screening for AF worthwhile? Stroke risk in a screened population from the SAFE study. Prevalence of atrial fibrillation in an urban population in India: the Nagpur pilot study Cryptogenic stroke and underlying atrial fibrillation. Atrial Fibrillation in Heart Failure With Preserved Ejection Fraction: The TOPCAT Trial. The incidence and risk factors for new onset atrial fibrillation in the PROSPER study. Subclinical atrial fibrillation in patients with recent transient ischemic attack Detection of Paroxysmal Atrial Fibrillation in Acute Stroke Patients
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 Background —Current methods for detecting atrial fibrillation ( AF ) have limited diagnostic yield . Continuous monitoring with automatic arrhythmia detection and classification may improve detection of symptomatic and asymptomatic AF and subsequent patient treatment . The study purpose was to quantify the performance of the first implantable leadless cardiac monitor ( ICM ) with dedicated AF detection capabilities . Methods and Results — Patients ( n=247 ) with an implanted ICM ( Reveal XT , Medtronic Inc , Minneapolis , Minn ) who were likely to present with paroxysmal AF were selected . A special Holter device stored 46 hours of subcutaneously recorded ECG , ICM markers , and 2 surface ECG leads . The ICM  automatic arrhythmia classification was compared with the core laboratory classification of the surface ECG . Of the 206 analyzable Holter recordings collected , 76 ( 37 % ) contained at least 1 episode of core laboratory classified AF . The sensitivity , specificity , positive predictive value , and negative predictive value for identifying patients with any AF were 96.1 % , 85.4 % , 79.3 % , and 97.4 % , respectively . The AF burden measured with the ICM was very well correlated with the reference value derived from the Holter ( Pearson coefficient=0.97 ) . The overall accuracy of the ICM for detecting AF was 98.5 % . Conclusions —In this ICM validation study , the dedicated AF detection algorithm reliably detected the presence or absence of AF and the AF burden was accurately quantified . The ICM is a promising new diagnostic and monitoring tool for the clinician to treat AF patients independently of symptoms . Long-term studies are needed to evaluate the clinical benefits of the technology . Clinical Trial Registration — clinical trials.gov Identifier NCT00680927 BACKGROUND Studies about continuous electrocardiographic ( ECG ) monitoring in detection of paroxysmal atrial fibrillation ( PAF ) in Asian patients with acute ischemic stroke are very limited . We looked for the prevalence and associated factors of atrial fibrillation ( AF ) and PAF in Thai patients with acute ischemic stroke . METHODS In all , 204 patients with acute ischemic stroke were prospect ively included .  Snapshot 12-lead ECG and continuous ECG monitoring for at least the first 24 hours were performed . Multivariate analyses were performed to find out the associated factors of AF and PAF . RESULTS AF was diagnosed in 31 patients ( 15 % ) and PAF in 15 patients ( 7 % ) . Twelve and 3 patients with PAF were diagnosed by continuous ECG monitoring and snapshot 12-lead ECG , respectively . Mean duration of continuous ECG monitoring and mean time to detect PAF were 55 and 23 hours , respectively . Multivariate analysis revealed that age of 70 years or older ( odds ratio [ OR ] 3.52 , 95 % confidence interval [ CI ] 1.68 - 7.35 , P = .001 ) and heart diseases ( OR 4.26 , 95 % CI 1.14 - 15.95 , P = .031 ) were associated with AF and PAF . CONCLUSIONS AF/PAF was one of the common causes of ischemic stroke in Thai patients . Most PAF was detected by continuous ECG monitoring . Snapshot 12-lead ECG and continuous ECG monitoring should be recommended in all patients with acute ischemic stroke Background : Asymptomatic atrial fibrillation ( AF ) is increasingly common in the aging population and implicated in many ischemic strokes . Earlier identification of AF with appropriate anticoagulation may decrease stroke morbidity and mortality . Methods : We conducted a r and omized controlled trial of AF screening using an AliveCor Kardia monitor attached to a WiFi-enabled iPod to obtain ECGs ( iECGs ) in ambulatory patients . Patients ≥65 years of age with a CHADS-VASc score ≥2 free from AF were r and omized to the iECG arm or routine care ( RC ) . iECG participants acquired iECGs twice weekly over 12 months ( plus additional iECGs if symptomatic ) onto a secure study server with overread by an automated AF detection algorithm and by a cardiac physiologist and /or consultant cardiologist . Time to diagnosis of AF was the primary outcome measure . The overall cost of the devices , ECG interpretation , and patient management were captured and used to generate the cost per AF diagnosis in iECG patients . Clinical events and patient attitudes/experience were also evaluated . Results : We studied 1001 patients ( 500 iECG , 501 RC ) who were 72.6±5.4 years of age ; 534 were female . Mean CHADS-VASc score was 3.0 ( heart failure , 1.4 % ; hypertension , 54 % ; diabetes mellitus , 30 % ; prior stroke/transient ischemic attack , 6.5 % ; arterial disease , 15.9 % ; all CHADS-VASc risk factors were evenly distributed between groups ) . Nineteen patients in the iECG group were diagnosed with AF over the 12-month study period versus 5 in the RC arm ( hazard ratio , 3.9 ; 95 % confidence interval=1.4–10.4 ; P=0.007 ) at a cost per AF diagnosis of $ 10 780 ( £ 8255 ) . There was a similar number of stroke/transient ischemic attack/systemic embolic events ( 6 versus 10 , iECG versus RC ; hazard ratio=0.61 ; 95 % confidence interval=0.22–1.69 ; P=0.34 ) . The majority of iECG patients were satisfied with the device , finding it easy to use without restricting activities or causing anxiety . Conclusions : Screening with twice-weekly single-lead iECG with remote interpretation in ambulatory patients ≥65 years of age at increased risk of stroke is significantly more likely to identify incident AF than RC over a 12-month period . This approach is also highly acceptable to this group of patients , supporting further evaluation in an appropriately powered , event-driven clinical trial . Clinical Trial Registration : URL : https://www.is rct n.com . Unique identifier : IS RCT N10709813 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 Screening for  atrial fibrillation ( AF ) by assessing the pulse is recommended in high-risk patients . Some clinical trials demonstrated that the Microlife blood pressure monitor ( BPM ) with AF detection is more accurate than pulse palpation . This led to a change in practice guidelines in the United Kingdom where AF screening with the Microlife device is recommended instead of pulse palpation . Many BPMs have irregular heart beat detection , but they have not been shown to detect AF reliably . Recently , one study , in a highly select population , suggested that the Omron BPM with irregular heart beat detection has a higher sensitivity for AF than the Microlife BPM . We compared the Microlife and Omron BPMs to electrocardiographic readings for AF detection in general cardiology patients . Inclusion criteria were age≥50 years without a pacemaker or defibrillator . A total of 199 subjects were enrolled , 30 with AF . Each subject had a 12-lead electrocardiography , 1 Omron BPM reading , and 3 Microlife BPM readings as per device instructions . The Omron device had a sensitivity of 30 % ( 95 % confidence interval [ CI ] 15.4 % to 49.1 % ) with the sensitivity for the first Microlife reading of 97 % ( 95 % CI 81.4 % to 100 % ) and the Microlife readings using the majority rule ( AF positive if at least 2 of 3 individual readings were positive for AF ) of 100 % ( 95 % CI 85.9 % to 100 % ) . Specificity for the Omron device was 97 % ( 95 % CI 92.5 % to 99.2 % ) and for the first Microlife reading of 90 % ( 95 % CI 83.8 % to 94.2 % ) and for the majority rule Microlife device of 92 % ( 95 % CI 86.2 % to 95.7 % ; p<0.0001 ) . The specificity of both devices is acceptable , but only the Microlife BPM has a sensitivity value that is high enough to be used for AF screening in clinical practice 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 Asymptomatic atrial fibrillation ( AF ) is a common cause of strokes . Physician screening for AF has been recommended . Home screening for AF may increase the likelihood of detecting asymptomatic AF in patients at risk for stroke because of AF . The aim of this study was to assess the feasibility and accuracy of screening for AF when taking home blood pressure ( BP ) measurements using an automatic AF-detecting BP monitor .  Subjects aged > 64 years or those with hypertension , diabetes , congestive heart failure , or previous stroke were enrolled by their primary physicians and given the AF-BP monitor and an electrocardiographic event monitor to use at home for 30 days . The AF-BP monitor reading was compared with the electrocardiographic reading to calculate the sensitivity and specificity of the device for detecting AF . A total of 160 subjects were enrolled , with 10 withdrawing , 1 excluded , and 10 with no AF-BP monitor logs or electrocardiographic recordings . Of the 139 subjects included , 14 had known AF . There was a total of 3,316 days with AF-BP monitor readings and electrocardiographic readings . On the basis of the initial daily AF-BP monitor readings , the AF-BP monitor demonstrated sensitivity of 99.2 % and specificity of 92.9 % for detecting AF . Two subjects with no histories of AF had AF-BP monitor readings of AF that were confirmed by the electrocardiographic monitor . One of these subjects was started on warfarin . In conclusion , home screening for asymptomatic AF while taking BP measurements can be performed accurately . This can be used to detect new AF , allowing treatment with anticoagulation to reduce the future risk for stroke 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 OBJECTIVES The present study determined the incidence and time course of atrial fibrillation ( AF ) recurrences  in patients with a history of AF and fitted with an implantable monitoring device .  BACKGROUND The long-term risk of undetected recurrence of AF in patients receiving stable antiarrhythmic therapy remains uncertain . METHODS In 110 patients with a class I indication for physiologic pacing and a history of AF , a pacemaker with dedicated functions for AF detection and electrogram storage was implanted , and antiarrhythmic drug treatment was optimized . Patients were regularly followed up with evaluation of AF-related symptoms , a  resting electrocardiogram ( ECG ) , and  interrogation of device memory .  The incidence of AF recurrences lasting > 48 h in asymptomatic patients presenting in sinus rhythm ( SR ) at the respective follow-up visit constituted the primary end point of this prospect i ve study . RESULTS During 19 + /- 11 months , 678 follow-up visits were performed . Atrial fibrillation was documented in 51 patients ( 46 % ) by ECG recording and in 97 patients ( 88 % ) by a review of stored electrograms ( p < 0.0001 ) . Device interrogation revealed AF recurrences lasting > 48 h in 50 patients , 19 of whom ( 38 % ) were completely asymptomatic and in SR at subsequent follow-up . In 11 ( 16 % ) of 67 patients with device-confirmed freedom from AF for > or =3 months , AF lasting > 48 h recurred subsequently . CONCLUSIONS This prospect i ve study demonstrates a high incidence of recurrent AF despite optimized antiarrhythmic therapy . Of particular note , AF relapses > 48 h remained totally asymptomatic in a significant proportion of patients . Freedom from AF for > or =3 months did not preclude subsequent long-lasting AF recurrence Atrial fibrillation ( AF ) is intermittent in 30 % of patients with cardioembolic stroke and , therefore , might not be seen in a single st and ard ECG recording . The aim of this study was to evaluate if prolonged ECG monitoring ( 96 h ) finds episodes of intermittent AF beyond the 24 h ECG monitoring in patients with cryptogenic stroke or transient ischemic attack ( TIA ) . We prospect ively evaluated consecutive patients affected by cryptogenic stroke or TIA who had sinus rhythm on a 12-lead ECG on admission , and during ECG monitoring performed in the acute phase ( for at least 24 h ) . Patients had continuous 96 h Holter ECG monitoring within 30 days from stroke onset . 114 patients were included in the study ( mean age 63.1 ± 15.1 , 59 males ) .  AF was found in 29 patients ( 24.3 % ) . In 20 patients , AF was found in the first 24 h of recording , and in nine patients after 24 h. In addition , several other dysrhythmias such as supraventricular ectopic activity ( 33 ) , ventricular tachycardia ( 10 ) , sinus pause ( 4 ) and sinus-atrial block ( 1 ) were found . In patients with cryptogenic stroke or TIA , 96 h ECG monitoring detected a high rate of AF . One-third of AF was seen beyond 24 h of ECG monitoring BACKGROUND Postoperative arrhythmias are among the most common complications of cardiac surgery . Total serum magnesium concentration will change after coronary bypass surgery but compensatory prophylactic administration of magnesium has remained a controversial issue . We studied whether prophylactic administration of magnesium could prevent post-coronary artery bypass grafting ( CABG ) arrhythmias and evaluated the effects of diabetes mellitus on prophylactic magnesium administration . METHODS In a clinical trial , 345 consecutive CABG c and i date s were r and omly assigned to study ( n = 166 , 48.1 % ) and control groups . Patients in study group received supplemental magnesium infusion as following : 2 g [ corrected ] after induction of anesthesia until cardio-pulmonary bypass and then 8 g upon arrival in Intensive Care Unit ( ICU ) until 24 hr . Total serum magnesium concentration was measured at four design ated time points : onset of induction , and 0 , 24 and 48 hr after ICU admission . Cardiac arrhythmias were sought with a 12-lead electrocardiogram ( ECG ) from the end of surgery up till discharge . RESULTS Atrial Fibrillation ( Af ) occurred in 34 patients ( 9.9 % ) . Total serum magnesium concentration was significantly higher in patients who received supplemental magnesium ( P < 0.001 ) and significantly lower in Af patients ( P= 0.02 ) . Among non-diabetics , Af incidence was significantly lower in study group compared with control group . CONCLUSIONS The occurrence of atrial fibrillation correlates with serum magnesium level . Diabetes mellitus probably hampers prophylactic effect of supplemental magnesium in preventing the occurrence of Af AIM Atrial fibrillation ( AF ) is associated with high morbidity and mortality . Early diagnosis is likely to improve therapy and prognosis . The study objective was to evaluate the usefulness of a programme for early diagnosis of AF in patients from an urban primary care centre . METHODS AND RESULTS Participants were recruited from a r and omized sample of patients not diagnosed with AF but having relevant risk factors : age ≥ 65 years , ischaemic and /or valvular heart disease , congestive heart failure , hypertension , and /or diabetes . Patients were r and omly assigned to the intervention group ( IG ) or control group ( CG ) . The intervention included ( i ) initial visit with clinical history , electrocardiogram , and instruction about pulse palpation and warning signs and ( ii ) electrocardiogram every 6 months during a 2-year follow-up . The main endpoint of the study was the proportion of new cases diagnosed at 6 months . Secondary endpoints were number of new AF diagnoses and complications associated with the arrhythmia in both groups . A total of 928 patients were included ( 463 IG and 465 CG ) . At 6 months , AF was diagnosed in 8 IG patients and 1 CG patient ( 1.7 vs. 0.2 % , respectively , P = 0.018 ) . After 2 years of follow-up , 11 IG patients and 6 CG patients had newly diagnosed AF ( 2.5 vs. 1.3 % , respectively , P = 0.132 ) . Time to first diagnosis of AF was shorter in IG patients [ median ( inter-quartile range ) : 7 ( 192 ) days vs. 227 ( 188.5 ) days in CG , P = 0.029 ] . CONCLUSION The simple screening proposed could be useful for the early detection of AF in primary care BACKGROUND Atrial fibrillation ( AF ) is a commonly encountered arrhythmia and occurs in up to 40 % of patients after coronary artery bypass surgery ( CABG ) . The preoperative signal averaged ECG ( SAECG ) P wave may be useful indicator of AF after CABG . We prospect ively analyzed the predictive value of SAECG P wave compared to clinical variables . METHODS Fifty-three patients with coronary artery disease undergoing first elective CABG were enrolled . All patients had P wave specific SAECG , st and ard 12 lead ECG , ejection fraction and left atrial posteroanterior diameter from the echocardiogram within the 24 h before surgery . From the SAECG P wave , filtered P wave duration was measured . Lead II P wave duration , left atrial enlargement and left ventricular hypertrophy were determined from st and ard ECG . Patients were continuously monitored during their postoperative period and serial ECGs were taken . RESULTS During an observation period of up to 16 days , 19 ( 35.8 % ) patients developed AF 2.8+/-1.3 days after CABG . Patients with AF more often had left atrial enlargement ( LAE ) on ECG ( P = 0.041 ) and right coronary artery ( RCA ) lesion ( P = 0.0034 ) . The filtered P wave duration on the SAECG was significantly longer in the AF patients than those without AF ( 129.7+/-13.2 ms versus 113.9+/-9.0 ms , P = 0.001 ) . Logistic regression analysis identified independent predictors , estimated adjusted relative risk ( 95 % confidence interval ) of AF : with LAE , the relative risk was 2.72 ( 1.13 - 5.82 ) , RCA lesion , the relative risk was 3.06 ( 1.45 - 6.45 ) and SAECG P wave duration > 122.3 ms , the relative risk was 4.58 ( 2.11 - 9.97 ) . The occurrence of AF was predicted by electrocardiographically determined left atrial enlargement with a sensitivity of 36 % , specificity of 88 % , positive predictive accuracy of 63 % , negative predictive accuracy of 71 % . If presence of right coronary artery lesion was evaluated these values were 63 % , 79 % , 63 % , 79 % subsequently . P wave duration > 122.3 ms had a sensitivity of 68 % , specificity of 88 % , positive predictive accuracy of 76 % , negative predictive accuracy of 83 % . If both P wave > 122.3 ms and presence of right coronary artery lesion were combined , these values were 47 % , 94 % , 81 % , 76 % subsequently . CONCLUSION The predictors of AF after CABG were left atrial enlargement on st and ard 12 lead ECG , RCA lesion and SAECG P wave duration . Among these predictors , SAECG P wave duration was the best predictor of AF after CABG Background and Purpose — For patients having suffered ischemic stroke , the current diagnostic strategies often fail to detect atrial fibrillation as a potential cause of embolic events . The aim of the study was to identify paroxysmal atrial fibrillation in stroke patients . We hypothesized that patients with frequent atrial premature beats ( APBs ) recorded in 24-hour ECG will show more often atrial fibrillation when followed by repeated long-term ECG recordings than patients without or infrequent APBs . Methods — 127 patients with acute ischemic stroke and without known AF were enrolled in a prospect i ve study to detect paroxysmal AF . Patients were stratified according to the number of APBs recorded in a 24-hour ECG ( ≥70 APBs versus < 70 APBs ) . Subsequently , they all underwent serial 7-day event-recorder monitoring at 0 , 3 , and 6 months . Results — Serial extended ECG monitoring  identified AF in 26 % of patients with frequent APBs but only in 6.5 % when APBs were infrequent ( P=0.0021 ) . A multivariate analysis showed that the presence of frequent APBs in the initial 24-hour ECG was the only independent predictor of paroxysmal AF during follow-up ( odds ratio 6.6 , 95 % confidence intervals 1.6 to 28.2 , P=0.01 ) . Conclusions — In patients with acute ischemic stroke , frequent APBs ( ≥70/24 hours ) are a marker for individuals who are at greater risk to develop or have paroxysmal AF . For such patients , we propose a diagnostic workup with repeated prolonged ECG monitoring to diagnose paroxysmal AF BACKGROUND Detection of undiagnosed or undertreated ( " actionable " ) atrial fibrillation could increase the use of appropriate oral anticoagulant therapy and reduce the risk of stroke . We sought to compare newer screening technologies with a pulse-check for the detection of atrial fibrillation and to determine whether the detection of actionable atrial fibrillation increases the use of oral anticoagulant agents . METHODS This prospect i ve multicentre cohort study involved 22 primary care clinics . We recruited participants aged 65 years and older who were attending routine appointments . Each participant underwent 3 methods of screening : a 30-second radial pulse-check ; single-lead electrocardiogram ; and screening by blood pressure machine with atrial fibrillation detection algorithms . Participants who received a positive result on 1 or more test underwent 12-lead electrocardiogram with or withour 24-hour Holter . Screening tests were compared using the McNemar test . Participants with confirmed atrial fibrillation received follow-up at 90 days . RESULTS The mean age of participants was 73.7 ( ± 6.9 ) years , and 53.4 % of participants were female . Of 2171 patients , we had data from all 3 screening tests for 2054 patients . Both single-lead electrocardiogram and the blood pressure device showed superior specificity compared with pulse-check ( p < 0.001 for each ) . Fifty-six patients ( 2.7 % ) had confirmed atrial fibrillation : 12 patients had newly detected atrial fibrillation ( none of the patients were using anticoagulation agents ) , and 44 patients had previously diagnosed atrial fibrillation ( 42 patients were receiving anticoagulant therapy , 2 were not ) . Thus , 14 patients had actionable atrial fibrillation ( 0.7 % ) . By 90 days , 77 % of patients with actionable atrial fibrillation had started anticoagulant therapy . INTERPRETATION Newer screening technologies showed superior specificity compared with a pulse-check . Screening detected undiagnosed or undertreated atrial fibrillation in 0.7 % of participants , and 77 % started appropriate anticoagulant therapy . TRIAL REGISTRATION Clinical Trials.gov , no. NCT02262351 INTRODUCTION Atrial fibrillation ( AF ) is an important independent risk factor for stroke and oral anticoagulation therapy provides a highly effective treatment to reduce this risk . Active screening strategies improve detection of AF in comparison with routine care ; however , whether screen-detected patients have stroke risk profiles favouring anticoagulation is unclear . Using data derived from the screening for AF in the elderly ( SAFE ) study , the aim of this article was to determine if patients with AF detected via active screening  have stroke risk profiles that warrant prophylactic anticoagulation . METHODS Secondary analysis of data derived from 25 general practice s within which cohorts of 200 patients were r and omly allocated to opportunistic [ pulse and electrocardiogram ( ECG ) ] or systematic screening ( postal invitation for ECG ) .  Stroke risk assessment was undertaken using baseline data extracted from medical records and CHADS2 criteria . CHADS2 scores were compared between the screening groups . RESULTS One hundred and forty-nine new cases of AF were detected , 75 via opportunistic screening and 74 via systematic screening . CHADS2 scores were ≥1 in 83 % [ 95 % confidence interval ( CI ) 72.6 - 89.6 ] of patients detected via opportunistic screening and 78 % ( 95 % CI 67.7 - 86.2 ) detected via systematic screening . There were no significant differences in stroke risk profiles of patients detected via opportunistic and systematic screenings . CONCLUSION Stroke risk profiles of patients detected via opportunistic and systematic screenings were similar . Data derived from the SAFE study suggest that active screening for AF in patients aged ≥65 years in primary care is a useful screening programme with 78 - 83 % of patients identified eligible for anticoagulation treatment according to the CHADS2 criteria Objectives Atrial fibrillation ( AF ) is the most common sustained arrhythmia encountered in clinical practice with major public health impact mainly due to the increased risk of stroke . The recent Global Burden of Disease Study reported a lack of prevalence data from India . Our goal was to conduct a pilot study to evaluate the feasibility of assessing AF prevalence and stroke prophylaxis in an urban Indian community . Methods A screening camp was conducted in Nagpur , India , that evaluated adults aged ≥18 years . We collected  demographics , recorded blood pressure , height , weight and the 12-lead electrocardiogram ( ECG ) .  The presence of diabetes and hypertension was recorded by self-reported history . Patients diagnosed with AF were evaluated further to assess aetiology and management . Results Of the total 4077 r and omly selected , community-dwelling adults studied , 0.196 % ( eight patients ) were found to have AF . Mean age of the population was 43.9±14.8 , and 44.5 % were female . The mean age of the patients with AF was 60.5±15.8 years ( five females )  . Rheumatic heart disease was found in five patients with AF . Three patients had history of stroke ( 37.5 % ) and one had peripheral arterial thrombosis . Three patients were on warfarin , but without routine international normalised ratio ( INR ) monitoring . One patient was on aspirin . Five patients were on β-blockers and one on both β-blocker and digoxin . Conclusions The prevalence of AF was low compared with other regions of the world and stroke prophylaxis was underused . A larger study is needed to confirm these findings . This study demonstrates that larger evaluations would be feasible using the community-based techniques employed here BACKGROUND Current guidelines recommend at least 24 hours of electrocardiographic ( ECG ) monitoring after an ischemic stroke to rule out atrial fibrillation . However , the most effective duration and type of monitoring have not been established , and the cause of ischemic stroke remains uncertain despite a complete diagnostic evaluation in 20 to 40 % of cases ( cryptogenic stroke ) . Detection of atrial fibrillation after cryptogenic stroke has therapeutic implication s. METHODS We conducted a r and omized , controlled study of 441 patients to assess whether long-term monitoring with an insertable cardiac monitor ( ICM ) is more effective than conventional follow-up ( control ) for detecting atrial fibrillation in patients with cryptogenic stroke . Patients 40 years of age or older with no evidence of atrial fibrillation during at least 24 hours of ECG monitoring  underwent r and omization within 90 days after the index event . The primary end point was the time to first detection of atrial fibrillation ( lasting > 30 seconds ) within 6 months . Among the secondary end points was the time to first detection of atrial fibrillation within 12 months . Data were analyzed according to the intention-to-treat principle . RESULTS By 6 months , atrial fibrillation had been detected in 8.9 % of patients in the ICM group ( 19 patients ) versus 1.4 % of patients in the control group ( 3 patients ) ( hazard ratio , 6.4 ; 95 % confidence interval [ CI ] , 1.9 to 21.7 ; P<0.001 ) . By 12 months , atrial fibrillation had been detected in 12.4 % of patients in the ICM group ( 29 patients ) versus 2.0 % of patients in the control group ( 4 patients ) ( hazard ratio , 7.3 ; 95 % CI , 2.6 to 20.8 ; P<0.001 ) . CONCLUSIONS ECG monitoring with an ICM was superior to conventional follow-up for detecting atrial fibrillation after cryptogenic stroke . ( Funded by Medtronic ; CRYSTAL AF Clinical Trials.gov number , NCT00924638 . ) OBJECTIVES This study assessed the relationship between atrial fibrillation ( AF ) and outcomes in the TOPCAT ( Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist ) trial , to evaluate whether AF modified the treatment response to spironolactone and whether spironolactone influenced post-r and omization AF . BACKGROUND AF is common in heart failure with preserved ejection fraction ( HFpEF ) and likely contributes to increased risk of adverse outcomes . METHODS A total 1,765 patients enrolled in TOPCAT trial in North and South America were divided into 3 groups : no known AF , history of AF without AF at enrollment  , and AF found on the electrocardiogram ( ECG ) at enrollment . We assessed outcomes and treatment response to spironolactone in all groups , and the association between post-r and omization AF and outcomes in patients free of AF at baseline . The primary outcome of the TOPCAT trial was a composite of cardiovascular mortality , aborted cardiac arrest , or heart failure hospitalization . RESULTS A total of 760 patients ( 43 % ) had a history of AF ( 18 % ) or AF on ECG at enrollment ( 25 % ) . The highest adjusted risk was associated with AF at enrollment ( primary outcome , hazard ratio : 1.34 ; 95 % confidence interval : 1.09 to 1.65 ; p = 0.006 ; and an increased early risk of secondary outcomes ) . Neither history of AF nor AF at enrollment modified the beneficial treatment effect of spironolactone . Post-r and omization AF , which occurred in 6.3 % of patients , was not influenced by spironolactone treatment , but was associated with an increased early risk of the primary outcome ( hazard ratio : 2.32 ; 95 % confidence interval : 1.59 to 3.40 ; p < 0.0001 ) and secondary outcomes . CONCLUSIONS AF at enrollment was associated with increased cardiovascular risk in HFpEF patients in the TOPCAT study . Post-r and omization AF , which was associated with an increased risk of morbidity and mortality , was not influenced by spironolactone . ( Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist [ TOPCAT ] ; NCT00094302 ) AIMS Atrial fibrillation/flutter ( AF ) is the most common arrhythmia in older people . It associates with reduced exercise capacity , increased risk of stroke , and mortality . We aim ed to determine retrospectively whether pravastatin reduces the incidence of AF and whether any electrocardiographic measures or clinical conditions might be risk factors for its development . METHODS AND RESULTS The PROspect i ve Study of Pravastatin in the Elderly at Risk ( PROSPER ) was a r and omized , double-blind controlled trial that recruited 5804 individuals aged 70 - 82 years with a history of , or risk factors for , vascular disease . A total of 2891 were allocated to pravastatin  and 2913 to  placebo ; mean follow-up was 3.2 years .  Electrocardiograms ( ECGs ) , which were recorded at baseline , annually thereafter , and at run-out , were processed by computer and review ed manually . In all , 264 of 2912 ( 9.1 % ) of the placebo group and 283 of 2888 ( 9.8 % ) of the pravastatin-treated group developed AF [ hazard ratio 1.08 ( 0.92,1.28 ) , P= 0.35 ) ] . Multivariate analysis showed that PR and QTc intervals , age , left ventricular hypertrophy , and ST-T abnormalities were related to development of AF after adjustment for many variables including alcohol consumption , which itself was univariately predictive of developing AF . Previous myocardial infa rct ion on the ECG was not a risk factor . A history of vascular disease was strongly linked with developing AF but not diabetes and hypertension . CONCLUSION Pravastatin does not reduce the incidence of AF in older people at risk of vascular disease , at least in the short-medium term . Risk factors for AF include older age , prolongation of PR or QTc intervals , left ventricular hypertrophy , and ST-T abnormalities on the ECG BACKGROUND Atrial fibrillation ( AF ) is a major risk factor of stroke , but the association between AF and transient ischemic attack ( TIA ) is less clear . Despite this , patients with TIA are included in stroke trials . AIMS To determine the 1-year incidence of AF in TIA patients using an insertable cardiac monitor ( ICM ) ; second , to determine factors associated with incident AF in these patients . METHODS Prospect i ve cohort study of patients with TIA with normal st and ard electrocardiogram ( ECG ) and 72-hour Holter monitoring ( HM ) . Exclusion criteria were as follows : age < 18 or > 81 years ; prior AF/stroke ; ongoing oral anticoagulation therapy or contraindication for it ; significant carotid artery stenosis ; uncertain TIA diagnosis . Eligible patients received an ICM and were followed for 12 months . RESULTS From November 2013 to October 2015 , 809 patients were diagnosed with TIA . In total , 235 patients were eligible . Nine ( 3.8 % ) of these had AF on st and ard ECG or HM . Of the remaining patients , 121 refused ICM implantation . In total , 105 patients ( median age 65.4 years [ range 27.1 - 80.8 ] , 46 % males ) received an ICM , which revealed AF in 7 ( 6.7 % ) . Factors associated with new-onset AF were a history of recurrent TIA ( odds ratio [ OR ] 11.5 , 95 % confidence interval [ CI ] 2.1 - 63.6 ) and heart failure ( OR 12.7 , 95 % CI 1.71 - 96.83 ) . CONCLUSIONS The 1-year incidence of AF in TIA patients with normal ECG and HM was 6.7 % using an ICM . Factors associated with development of AF were recurrent TIA and heart failure Background : Atrial fibrillation ( AF ) is a frequent cause of stroke , but detecting paroxysmal AF ( pAF ) poses a challenge . We investigated whether continuous bedside ECG monitoring in a stroke unit detects pAF more sensitively than 24-hour Holter ECG , and tested whether examining RR interval dynamics on short-term ECG recordings using an automated screening algorithm ( ASA ) for pAF detection is a useful tool to predict the risk of pAF outside periods of manifest AF . Methods : Patients > 60 years with acute ischemic stroke or transient ischemic attacks ( TIA ) were prospect ively enrolled unless initial ECG revealed AF or they had a history of paroxysmal or persistent AF . ASA was performed on 1- to 2-hour ECG recordings in the emergency room and patients were classified into 5 risk categories for pAF . All patients underwent continuous bedside ECG monitoring for > 48 h. Additionally , 24-hour Holter ECG was performed . Results : 136 patients were enrolled ( median age : 72 years , male : 58.8 % ) . In 29 ( 21.3 % ) , pAF was newly diagnosed by continuous bedside ECG monitoring . pAF increased with age ( p = 0.031 ) . Median time to first pAF detection on continuous bedside ECG monitoring was 36 h. In 16 patients , pAF was detected by continuous bedside ECG monitoring prior to the performance of 24-hour Holter ECG . Thirteen of the remaining patients were pAF positive on continuous bedside ECG monitoring , but 24-hour Holter detected only 3 patients . Accordingly , the sensitivity of 24-hour Holter was 0.23 . Sensitivity of higher-risk categories of ASA compared to continuous bedside ECG monitoring was 0.72 , and specificity 0.63 . Conclusion : Continuous bedside ECG monitoring is more sensitive than 24-hour Holter ECG for pAF detection in acute stroke/TIA patients . Screening patients for pAF outside AF episodes using ASA requires further development
Kardia Mobile is the most cost effective option in a full incremental analysis .
Lead-I ECG tests may identify more AF cases than the st and ard diagnostic pathway .
This comes at a higher cost but with greater patient benefit in terms of mortality and quality of life .
Conclusions The use of single-time point lead-I ECG devices in primary care for the detection of AF in people with signs or symptoms of AF and an irregular pulse appears to be a cost effective use of NHS re sources compared with MPP followed by a 12-lead ECG , given the assumptions used in the base case model .
Background Atrial fibrillation ( AF ) is the most common type of cardiac arrhythmia and is associated with increased risk of stroke and congestive heart failure .
Lead-I electrocardiogram ( ECG ) devices are h and held instruments that can detect AF at a single-time point .
Purpose To assess the diagnostic test accuracy , clinical impact and cost effectiveness of single-time point lead-I ECG devices compared with manual pulse palpation ( MPP ) followed by a 12-lead ECG for the detection of AF in symptomatic primary care patients with an irregular pulse .