Screening for Atrial Fibrillation and Hypertension: time to act now

During the ESC 2024 OMRON Healthcare hosted a Satellite Symposium on 1 September 2024 - 10.00 - 10.45 BST.

At the end some questions from the online audience remained unanswered. Here are the questions and the answers prepared by Prof. Freedman, Prof. Schutte and Prof. Schnabel.

1.What is the best screening tool in daily practice? 12 lead ECG and 24 h holter are both are not sensitive enough
Important to separate the question of ECG-method and the duration or intensity of  screening. A single timepoint ECG screen whether single-lead rhythm strip or 12-lead ECG has low sensitivity, but if AF detected it is usually persistent or high burden AF, with the same stroke risk as clinical AF. Holter monitor for 24 hour is only slightly more sensitive, but also detects high burden high risk AF. In daily practice, multiple single time ECG rhythm strip screens have greater sensitivity and still detect AF of high enough risk to treat. Implanted or inserted ECG monitors have the highest sensitivity in detecting AF, but the increased detection of lower burden AF is likely to have lower stroke risk

2. How often would you recommend BP measurement as screening in patients with risk factors?
In patient at high risk, it is recommended to screen for BP on an annual basis, with annual follow-up. In fact, for all adults older than 40 years annual screening is recommended.

3. How long do we need atrial fibrillation to define risk for treating with aco?
AF duration of 30 sec is sufficient to diagnose the arrhythmia. If this is a single timepoint measurement, then the AF is usually persistent or high burden, which will benefit from OAC (depending on CHA₂DS₂VA Score). If the AF is detected on long-term continuous ECG monitoring, then longer durations with longer AF burdens) are likely to have a high enough stroke risk to justify OAC, but there is as yet no definite AF duration cut-off to define this, and there is also an interaction with CHA₂DS₂VA Score.

4. In which patients would you recommend studying biomarkers in a primary care setting?
For hypertension, high-sensitivity cardiac troponin or B-type natriuretic peptide biomarkers may be considered for refined cardiovascular disease risk estimation with a class IIb, B recommendation in the new ESC guidelines, to improve risk stratification among patients with borderline increased 10-year CVD risk (5% to <10%) to support treatment decisions.

For screening and early detection of AF, there are no specific recommendations regarding biomarkers in the 2024 ESC guidelines that encourage specific biomarker measurements. Circulating biomarkers and genetics have been robustly associated with incident AF in observational studies. However, clear cost effectiveness and decision thresholds have not been shown. Consistently reported biomarkers are C-reactive protein, fibrinogen, growth differentiation factor-15, natriuretic peptides (atrial and B-type), cardiac troponins and inflammatory biomarkers. The STROKESTOP II AF screening study recently demonstrated that the measurement of NT-proBNP in 75/76-year-olds can safely identify individuals at low risk of AF and stroke. Whether biomarkers can be used for refined AF screening still needs to be demonstrated.

5. What value do you give to the amount of atrial fibrosis as a risk marker? With score of Utah
Left Atrial fibrosis as a marker of atrial myopathy should still be regarded  as an investigational tool.  It has been difficult to replicate the MRI measurements made by the Marrouche group in Utah, and for the moment is unlikely to become readily available to use as a marker to guide screening or risk estimation. AF is more likely to occur in patients with Atrial myopathy and fibrosis, and the presence of atrial myopathy/significant fibrosis is likely to be a risk marker for stroke in those with AF. These issues are under active investigation.