Department of Cardiology, Rigshospitalet (S.Z.D., L.K., J.H.S.).
Department of Cardiology, Zealand University Hospital Roskilde, Denmark (K.J.H.).
Circulation. 2020 May 12;141(19):1510-1522. doi: 10.1161/CIRCULATIONAHA.119.044407. Epub 2020 Mar 2.
Stroke is an increasing health problem worldwide. Atrial fibrillation (AF) is a major risk factor for stroke, and the attention given to AF screening is rising, as new monitoring technologies emerge. We aimed to evaluate the performance of a large panel of screening strategies and to assess population characteristics associated with diagnostic yield.
Individuals with stroke risk factors but without AF were recruited from the general population to undergo screening with an implantable loop recorder. New-onset AF lasting ≥6 minutes was adjudicated by senior cardiologists. After continuous monitoring for >3 years, complete day-to-day heart rhythm data sets were reconstructed for every participant, including exact time of onset and termination of all AF episodes. Random sampling was applied to assess the sensitivity and negative predictive value of screening with various simulated screening strategies compared with the implantable loop recorder. The diagnostic yield across strategies and population subgroups was compared by use of nonparametric tests.
The rhythm data sets comprised 590 participants enduring a total of 659 758 days of continuous monitoring and 20 110 AF episodes. In these data, a single 10-second ECG yielded a sensitivity (and negative predictive value) of 1.5% (66%) for AF detection, increasing to 8.3% (67%) for twice-daily 30-second ECGs during 14 days and to 11% (68%), 13% (68%), 15% (69%), 21% (70%), and 34% (74%) for a single 24-hour, 48-hour, 72-hour, 7-day, or 30-day continuous monitoring, respectively. AF detection further improved when subsequent screenings were performed or when the same monitoring duration was spread over several periods compared with a single period (eg, three 24-hour monitorings versus one 72-hour monitoring; <0.0001 for all comparisons). The sensitivity was consistently higher among participants with age ≥75 years, male sex, CHADS score >2, or NT-proBNP (N-terminal pro-B-type natriuretic peptide) ≥40 pmol/L and among participants with underlying ≥24-hour AF episodes compared with shorter AF (<0.0001 for all screening strategies).
In screening for AF among participants with stroke risk factors, the diagnostic yield increased with duration, dispersion, and number of screenings, although all strategies had low yield compared with the implantable loop recorder. The sensitivity was higher among participants who were older, were male, or had higher NT-proBNP. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02036450.
中风是全球日益严重的健康问题。心房颤动（AF）是中风的一个主要危险因素，随着新监测技术的出现，对 AF 筛查的重视程度正在提高。我们旨在评估大量筛查策略的性能，并评估与诊断率相关的人群特征。
从普通人群中招募有中风危险因素但无 AF 的个体，使用植入式环路记录器进行筛查。新发生的持续时间≥6 分钟的 AF 由资深心脏病专家判定。在连续监测>3 年后，为每位参与者重建了完整的日常心律数据组，包括所有 AF 发作的开始和结束的确切时间。应用随机抽样评估了与植入式环路记录器相比，各种模拟筛查策略的敏感性和阴性预测值。通过使用非参数检验比较了不同策略和人群亚组的诊断率。
节律数据集包括 590 名参与者，共经历了 659758 天的连续监测和 20110 次 AF 发作。在这些数据中，单次 10 秒心电图的敏感性（和阴性预测值）为 1.5%（66%），可检测到 AF，每天两次 30 秒心电图监测 14 天，敏感性增加到 8.3%（67%），分别为 11%（68%）、13%（68%）、15%（69%）、21%（70%）和 34%（74%）。单次 24 小时、48 小时、72 小时、7 天或 30 天连续监测时，AF 检测进一步改善。与单次监测相比，随后进行监测或在多个时间段内进行相同的监测时间，AF 检测率更高（例如，三次 24 小时监测与一次 72 小时监测相比；所有比较均<0.0001）。与持续时间较短的 AF（所有筛查策略均<0.0001）相比，年龄≥75 岁、男性、CHADS 评分>2 或 NT-proBNP（N 端脑利钠肽前体）≥40pmol/L 的参与者以及有潜在的≥24 小时 AF 发作的参与者的敏感性更高。
在筛查有中风危险因素的参与者的 AF 时，诊断率随着持续时间、分散度和筛查次数的增加而增加，尽管与植入式环路记录器相比，所有策略的诊断率都较低。敏感性在年龄较大、男性或 NT-proBNP 较高的参与者中更高。注册：网址：https://www.clinicaltrials.gov；唯一标识符：NCT02036450。
