Should all patients with atrial fibrillation be screened with echocardiography?

OBJECTIVE

To address a patient care problem suggested by a quality assurance study: Should physicians of patients with atrial fibrillation who have not had echocardiography performed be encouraged to obtain echocardiograms in order to discover heretofore undetected mitral stenosis, which could be treated with anticoagulation, in order to avert strokes?

DESIGN

Decision analysis using a Markov-chain technique and quality-adjusted life expectancy.

SETTING

Outpatient clinics.

PATIENTS

Patients aged 40-80 years with chronic atrial fibrillation.

INTERVENTIONS

The following strategies were studied: 1) obtain echocardiograms for all patients and anticoagulate those with mitral stenosis; 2) anticoagulate patients with classic auscultatory sounds of mitral stenosis and obtain echocardiograms for patients with other murmurs; if an echocardiogram reveals mitral stenosis, anticoagulate; 3) anticoagulate all patients with murmurs; 4) anticoagulate all patients; 5) observe all patients (natural history).

MAIN RESULTS

The base analysis, using data available in the literature and on site, indicated that though performing echocardiography on all patients with atrial fibrillation gave the best quality-adjusted life expectancy, the differences among the five strategies studied were small. In addition, sensitivity analysis revealed that the decision was sensitive to many of the variables used in the analysis, especially the efficacy and the risks of anticoagulation.

CONCLUSION

A recommendation that cardiac ultrasonography be done for all patients with atrial fibrillation in order to detect clinically unrecognized mitral stenosis cannot be made.