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BACKGROUND Internationally, most atrial fibrillation (AF) management guidelines recommend opportunistic screening for AF in people ≥65 years of age and oral anticoagulant treatment for those at high stroke risk (CHA₂DS₂-VA≥2). However, gaps remain in screening and treatment. METHODS AND RESULTS General practitioners/nurses at practices in rural Australia (n=8) screened eligible patients (≥65 years of age without AF) using a smartphone ECG during practice visits. eHealth tools included electronic prompts, guideline-based electronic decision support, and regular data reports. Clinical audit tools extracted de-identified data. Results were compared with an earlier study in metropolitan practices (n=8) and nonrandomized control practices (n=69). Cost-effectiveness analysis compared population-based screening with no screening and included screening, treatment, and hospitalization costs for stroke and serious bleeding events. Patients (n=3103, 34%) were screened (mean age, 75.1±6.8 years; 47% men) and 36 (1.2%) new AF cases were confirmed (mean age, 77.0 years; 64% men; mean CHA₂DS₂-VA, 3.2). Oral anticoagulant treatment rates for patients with CHA₂DS₂-VA≥2 were 82% (screen detected) versus 74% (preexisting AF)( P =NS), similar to metropolitan and nonrandomized control practices. The incremental cost-effectiveness ratio for population-based screening was AU$16 578 per quality-adjusted life year gained and AU$84 383 per stroke prevented compared with no screening. National implementation would prevent 147 strokes per year. Increasing the proportion screened to 75% would prevent 177 additional strokes per year. CONCLUSIONS An AF screening program in rural practices, supported by eHealth tools, screened 34% of eligible patients and was cost-effective. Oral anticoagulant treatment rates were relatively high at baseline, trending upward during the study. Increasing the proportion screened would prevent many more strokes with minimal incremental cost-effectiveness ratio change. eHealth tools, including data reports, may be a valuable addition to future programs. REGISTRATION URL: https://www.anzctr.org.au. Unique identifier: ACTRN12618000004268.

Background: Screening for atrial fibrillation (AF) in people aged ≥65 years is recommended by international guidelines. The Atrial Fibrillation Screen, Management And guideline-Recommended Therapy (AF-SMART) studies of opportunistic AF screening in 16 metropolitan and rural general practices were conducted from November 2016-June 2019. These studies trialled custom-designed eHealth tools to support all stages of AF screening in general practice., Methods: A realist evaluation of the AF-SMART studies, which aimed to explain the circumstances in which the program worked (or not) to increase the proportion of people screened for AF. The initial program theory was based on our previous research, policy documents and screening studies. To test this, we conducted 45 semi-structured interviews with general practitioners (GPs), nurses and practice managers across all participating practices, and collected observational and quantitative screening data. These data were analysed and interpreted to refine the program theory., Results: GPs/nurses liked the eHealth tools, although technical problems sometimes disrupted screening. Time was the main barrier to screening for GPs/nurses, so systems need to be very efficient. Practices with leadership from a senior GP 'screening champion' had broader uptake, especially from the nursing team. Providing regular feedback on screening data was beneficial for quality improvement and motivation. Clear protocols for follow-up of abnormal results were required for successful nurse-led screening in a hierarchical system. Participation in the program had broader benefits of improving AF knowledge and raising the profile of cardiovascular health in the practice. Screening for a shorter, more intense period (eg during influenza vaccination) worked well for practices where sufficient staff time was allocated., Conclusions: Introducing an AF screening program is likely to be successful in contexts where there is a senior GP 'screening champion', a clear protocol exists for abnormal results, and there is regular data reporting to staff. These contexts link to mechanisms around motivation, leadership, empowerment of nurses, and efficient screening systems. The contexts and mechanisms contribute to the longer-term outcomes of increasing the proportion of people screened and treated for AF, which is recommended by guidelines as a key strategy for the prevention of AF-related stroke., Trial Registrations: AF SMART (metropolitan): ACTRN12616000850471 (Australia New Zealand Clinical Trials Registry). AF SMART II (rural): ACTRN12618000004268 (Australia New Zealand Clinical Trials Registry).

Background: The precise age distribution and calculated stroke risk of screen-detected atrial fibrillation (AF) is not known. Therefore, it is not possible to determine the number needed to screen (NNS) to identify one treatable new AF case (NNS-Rx) (i.e., Class-1 oral anticoagulation [OAC] treatment recommendation) in each age stratum. If the NNS-Rx is known for each age stratum, precise cost-effectiveness and sensitivity simulations can be performed based on the age distribution of the population/region to be screened. Such calculations are required by national authorities and organisations responsible for health system budgets to determine the best age cutoffs for screening programs and decide whether programs of screening should be funded. Therefore, we aimed to determine the exact yield and calculated stroke-risk profile of screen-detected AF and NNS-Rx in 5-year age strata., Methods and Findings: A systematic review of Medline, Pubmed, and Embase was performed (January 2007 to February 2018), and AF-SCREEN international collaboration members were contacted to identify additional studies. Twenty-four eligible studies were identified that performed a single time point screen for AF in a general ambulant population, including people ≥65 years. Authors from eligible studies were invited to collaborate and share patient-level data. Statistical analysis was performed using random effects logistic regression for AF detection rate, and Poisson regression modelling for CHA2DS2-VASc scores. Nineteen studies (14 countries from a mix of low- to middle- and high-income countries) collaborated, with 141,220 participants screened and 1,539 new AF cases. Pooled yield of screening was greater in males across all age strata. The age/sex-adjusted detection rate for screen-detected AF in ≥65-year-olds was 1.44% (95% CI, 1.13%-1.82%) and 0.41% (95% CI, 0.31%-0.53%) for <65-year-olds. New AF detection rate increased progressively with age from 0.34% (<60 years) to 2.73% (≥85 years). Neither the choice of screening methodology or device, the geographical region, nor the screening setting influenced the detection rate of AF. Mean CHA2DS2-VASc scores (n = 1,369) increased with age from 1.1 (<60 years) to 3.9 (≥85 years); 72% of ≥65 years had ≥1 additional stroke risk factor other than age/sex. All new AF ≥75 years and 66% between 65 and 74 years had a Class-1 OAC recommendation. The NNS-Rx is 83 for ≥65 years, 926 for 60-64 years; and 1,089 for <60 years. The main limitation of this study is there are insufficient data on sociodemographic variables of the populations and possible ascertainment biases to explain the variance in the samples., Conclusions: People with screen-detected AF are at elevated calculated stroke risk: above age 65, the majority have a Class-1 OAC recommendation for stroke prevention, and >70% have ≥1 additional stroke risk factor other than age/sex. Our data, based on the largest number of screen-detected AF collected to date, show the precise relationship between yield and estimated stroke risk profile with age, and strong dependence for NNS-RX on the age distribution of the population to be screened: essential information for precise cost-effectiveness calculations., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: GYHL reports consultancy and speaker fees from Bayer, Bayer/Janssen, BMS/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Microlife, Roche, and Daiichi-Sankyo outside the submitted work. No fees were received personally. YC reports grants from Bayer during the conduct of the study. DDM reports grants from National Institutes of Health, grants and other research support from Bristol Myers Squibb, Pfizer, Boehringer Ingelheim, grants, personal fees and other from Bristol Myers Squibb and Pfizer, other research support from Apple, Samsung Electronics, grants from National Science Foundation during the conduct of the study; other from Mobile Sense Technologies and grants from Philips outside the submitted work. MP reports consultancy activity for Boehringer Ingelheim. JJO reports grants from Pfizer, nonfinancial support from Alivecor, outside the submitted work. JW reports grants from Bayer during the conduct of the study. GHM reports grants from Belgian Heart Rhythm Association during the conduct of the study; personal fees from Boehringer Ingelheim, Bayer, Daiichi Sankyo, BMS/Pfizer, St Jude Medical outside the submitted work. RBS reports personal fees from Bristol-Myers Squibb/Pfizer Pharma outside the submitted work. JSH reports grants from Medtronic, grants from Bristol-Meyers-Squibb/Pfizer outside the submitted work. FDRH reports personal fees from BMS/Pfizer, BI, and Bayer outside the submitted work. FRQ reports personal fees from Bayer, personal fees from Servier, grants from Bayer, grants from Boehringer Ingelheim, personal fees from BMS outside the submitted work. BF reports grants, personal fees and nonfinancial support from Bayer, grants, personal fees and nonfinancial support from BMS-Pfizer, personal fees and non-financial support from Daiichi-Sankyo outside the submitted work. PSW reports grants and personal fees from Boehringer Ingelheim, grants from Philips Medical Systems, grants and personal fees from Sanofi-Aventis, grants and personal fees from Bayer Vital, grants from Daiichi Sankyo Europe, personal fees from Bayer HealthCare, personal fees from Astra Zeneca, personal fees and nonfinancial support from DiaSorin, nonfinancial support from I.E.M., grants from Evonik, outside the submitted work. FK reports grants from Boehringer Ingelheim outside the submitted work. RT reports grants and personal fees from Boehringer Ingelheim during the conduct of the study. In addition, RT has a patent as a co-inventor of the MyDiagnostick with royalties paid. The following authors have declared that no competing interests exist: VWL, AD, JH, NL, JO, LAPDT, AKR, RKS, SAC, TFC, JN, EMR, WK, JM, JM, LN, JWM, BPY, TM, JJGD, AS, BS, JSL, and DAF.

Background This eH ealth implementation study aimed to evaluate strategies to promote opportunistic atrial fibrillation ( AF ) screening using electronic screening prompts and improve treatment using electronic decision support ( EDS ) software. Methods and Results An electronic screening prompt appeared whenever an eligible patient's (aged ≥65 years, no AF diagnosis) medical record was opened in participating general practices. General practitioners and practice nurses offered screening using a smartphone ECG, with validated AF algorithm. Guideline-based EDS was provided to assist treatment decisions. Deidentified data were collected from practices using a data extraction tool. General practices (n=8) across Sydney, Australia, screened for a median of 6 months. A total of 1805 of 11 476 (16%) eligible patients who attended were screened (44% men, mean age 75.7 years). Screening identified 19 (1.1%) new cases of AF (mean age, 79 years; mean CHA 2 DS 2 - VAS c, 3.7; 53% men). General practitioners (n=30) performed 70% of all screenings (range 1-448 patients per general practitioner). The proportion of patients with AF who had CHA 2 DS 2 - VAS c ≥2 for men or ≥3 for women prescribed oral anticoagulants was higher for those diagnosed during the study: 15 of 18 (83%) for screen-detected and 39 of 46 (85%) for clinically detected, compared with 933 of 1306 (71%) patients diagnosed before the study ( P<0.001). The EDS was accessed 111 times for patients with AF and for 4 of 19 screen-detected patients. Conclusions The eH ealth tools showed promise. Adherence to guideline-based oral anticoagulant prescription was significantly higher in patients diagnosed during the study period, although the EDS was only used in a minority. While the proportion of eligible patients screened and EDS use was relatively low, further refinements may improve uptake in clinical practice. Clinical Trial Registration URL : www.anzctr.org.au . Unique identifier: ACTRN 12616000850471.

Introduction: Screening for atrial fibrillation (AF) in people ≥65 years is now recommended by guidelines and expert consensus. While AF is often asymptomatic, it is the most common heart arrhythmia and is associated with increased risk of stroke. Early identification and treatment with oral anticoagulants can substantially reduce stroke risk. The general practice setting is ideal for opportunistic screening and provides a natural pathway for treatment for those identified.This study aims to investigate the feasibility of implementing screening for AF in rural general practice using novel electronic tools. It will assess whether screening will fit within an existing workflow to quickly and accurately identify AF, and will potentially inform a generalisable, scalable approach., Methods and Analysis: Screening with a smartphone ECG will be conducted by general practitioners and practice nurses in rural general practices in New South Wales, Australia for 3-4 months during 2018-2019. Up to 10 practices will be recruited, and we aim to screen 2000 patients aged ≥65 years. Practices will be given an electronic screening prompt and electronic decision support to guide evidence-based treatment for those with AF. De-identified data will be collected using a clinical audit tool and qualitative interviews will be conducted with selected practice staff. A process evaluation and cost-effectiveness analysis will also be undertaken. Outcomes include implementation success (proportion of eligible patients screened, fidelity to protocol), proportion of people screened identified with new AF and rates of treatment with anticoagulants and antiplatelets at baseline and completion. Results will be compared against an earlier metropolitan study and a 'control' dataset of practices., Ethics and Dissemination: Ethics approval was received from the University of Sydney Human Research Ethics Committee on 27 February 2018 (Project no.: 2017/1017). Results will be disseminated through various forums, including peer-reviewed publication and conference presentations., Trial Registration Number: ACTRN12618000004268; Pre-results., Competing Interests: Competing interests: NL and BF report grants from BMS/Pfizer during the conduct of the study. RW and AP report other financial interests from George Health, outside the submitted work. CF reports personal fees from Pfizer outside the submitted work. LN reports grants from Pfizer/BMS and Boehringer Ingelheim outside the submitted work. BF reports prior fees and advisory board honoraria from Bayer Pharma AG, Boehringer Ingelheim, and BMS/Pfizer but for the past year has removed himself from pharmaceutical advisory boards and receives speaker fees only for accredited educational meetings., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Atrial fibrillation (AF) developing after cardiac surgery is the most common postoperative complication with an incidence up to 50%. The presence of postoperative AF is associated with significant morbidity, mortality and economic burden. However, in Vietnam, data on AF postcardiac surgery are limited, in part due to a shortage of screening equipment. This project aims to identify the incidence, risk factors and postoperative complications of new-onset postoperative AF after cardiac surgery, and the feasibility of introducing a novel screening strategy using the combination of two portable devices to detect AF., Methods and Analysis: This is a feasibility study examining patients who are (1) ≥18 years old; (2) undergoing coronary artery bypass graft and/or valve surgery and (3) in normal sinus rhythm prior to their operation. Patients with congenital heart disease, a prior history of AF or those who require a pacemaker after surgery will be excluded. All patients will be followed up for the duration of their hospitalisation. The screening strategy will include monitoring the continuous ECG tracing in the intensive care unit, and if AF is suspected, a 30 s lead-1 ECG will be recorded using the smartphone-based AliveCor Kardia Mobile. On the postoperative wards, blood pressure will be measured three times daily using a modified blood pressure device (Microlife BP200 Afib): and if AF is suspected a 30 s ECG will be recorded using the AliveCor Kardia Mobile. A 12-lead ECG may be ordered subsequently if clinically indicated. The primary outcome is the incidence of postoperative AF. Secondary outcomes include establishing the risk factors and complications associated with postoperative AF; and the barriers and facilitators of the screening strategy., Ethics and Dissemination: Ethics approval was granted by Scientific Board of Cardiovascular Centre, E Hospital on 28 September, 2017. Study results will be disseminated through local and international conferences and peer-reviewed publications., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Atrial fibrillation (AF) is the most common cardiac arrhythmia, with a lifetime risk of one in four of developing AF over the age of 40 years. Around 40% of patients are asymptomatic, which is of concern as AF is a major risk factor for stroke. Early detection and appropriate management reduces stroke risk by two-thirds. Atrial fibrillation screening is now recommended in international guidelines, but there are some common arguments against screening. Overall, to be of value any screening program must fulfil the World Health Organization (WHO) Wilson and Jungner criteria for screening programs. In this paper we address the common arguments, and determine if AF screening fulfils the WHO criteria., (Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base., (© 2017 American Heart Association, Inc.)

Background: People with unknown atrial fibrillation (AF), who are often asymptomatic, have a substantially increased risk of stroke. Although recommended in European guidelines, AF screening is not routinely performed. Screening at the time of influenza vaccination presents an ideal opportunity to detect AF in large numbers in a primary care medical setting, with an existing annual recall system for patients aged ≥65 years., Design: Cross-sectional pilot study of handheld smartphone electrocardiogram (iECG) screening to identify unknown AF., Methods: General practices in Sydney, Australia, were recruited during the influenza-vaccination period of April-June 2015. Practice nurses screened patients aged ≥65 years with a 30-second iECG, which has a validated algorithm for detecting AF in real time. In order to confirm the accuracy of the algorithm, two research cardiologists reviewed de-identified iECGs. In order to explore barriers and enablers, semi-structured interviews were conducted with selected nurses, practice managers and general practitioners., Results: Five general practices were recruited, and 973/2476 (39%) patients attending influenza vaccination were screened. Screening took an average of 5 minutes (range 1.5-10 minutes); however, abnormal iECGs required additional time. Newly identified AF was found in 8/973 patients (0.8%). The sensitivity of the iECG automated algorithm was 95% (95% confidence interval: 83-99%) and the specificity was 99% (95% confidence interval: 98-100%). Screening by practice nurses was well accepted by practice staff. Key enablers were the confidence and competence of nurses and a 'designated champion' to lead screening at the practice. Barriers were practice specific, and mainly related to staff time and funding., Conclusions: Screening with iECG during influenza vaccination by primary care nurses is feasible and well accepted by practice staff. Addressing barriers is likely to increase uptake., (© The European Society of Cardiology 2016.)