Short-term and intermittent ECG-based screening for atrial fibrillation in older adults without known atrial fibrillation: a GRADE-assessed meta-analysis of randomized trials with time-to-event data

Abstract

Non-invasive ECG-based screening for atrial fibrillation (AF) in older adults may increase detection of silent AF and uptake of oral anticoagulation (OAC), but screening strategies, AF definitions, AF burden, and downstream treatment thresholds vary across trials. We performed a a GRADE-assessed meta-analysis of randomized controlled trials (RCTs) comparing short-term or intermittent non-invasive ECG-based AF screening strategies versus usual care, opportunistic detection, or no invitation in older adults without known AF. For dichotomous outcomes, pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using random-effects models. Trial sequential analysis (TSA) assessed conclusiveness of evidence. Across seven RCTs involving 77,526 participants (38,770 assigned to ECG-based screening and 38,756 to control group), screening increased new AF diagnoses compared with control (RR 1.76, 95% CI 1.21–2.56; moderate-certainty). ECG-based screening also increased new OAC initiation (RR 1.78, 95% CI 1.13–2.81; moderate-certainty). However, there were no significant differences in stroke or systemic embolism (RR 0.95, 95% CI 0.89–1.01), all-cause mortality (RR 0.98, 95% CI 0.95–1.02), or major bleeding (RR 0.98, 95% CI 0.92–1.05). Exploratory subgroup analyses by screening framework did not show statistically significant subgroup differences for AF detection, stroke/systemic embolism, mortality, or major bleeding. TSA indicated that evidence for AF detection and clinical outcomes remains inconclusive. Short-term and intermittent ECG-based AF screening in older adults without known AF increases trial-defined AF detection and OAC initiation but has not demonstrated reductions in stroke, mortality, or major bleeding. Current evidence supports a cautious, risk-based screening approach rather than broad population-wide implementation.