I'm Melissa Brown, I'm a physician assistant working in cardiac electrophysiology at Emory, and I'll be presenting on screening from the Risk Busters Mastering AFib Prevention and Lifestyle Upgrades series. I have no relevant financial disclosures. So the rationale for monitoring times when we use monitoring would be for the initial screening or diagnosis of atrial fibrillation. For patients who have risk factors or have had palpitations or are high risk for developing atrial fibrillation, we can use monitoring techniques to find subclinical atrial fibrillation as well. For patients with a history of AFib, monitoring devices can help detect recurrent episodes. And then also, after we've treated atrial fibrillation, we can use these monitoring techniques to assess the responsiveness or efficacy of our treatment therapy. I'd like to start by simply reviewing our different screening modalities for atrial fibrillation. So the gold standard for AFib diagnosis is still the 12-lead EKG or ECG. It provides a snapshot of the rhythm at a single point in time from several views. So it's easiest to see those fibrillation waves. It's best for symptomatic patients or for routine clinic screening. Of course, when we're taking just one moment in time, it can miss paroxysmal atrial fibrillation. And this is an external cardiac monitor, such as Holter monitors or MCOTs, which can continuously record the rhythm for over days to weeks. So up to 30 days. And it's useful for detecting intermittent atrial fibrillation without having to have an intervention. Next, our implantable loop recorders are subcutaneous devices that monitor the rhythm continuously for around three years. They're excellent for detecting infrequent or asymptomatic atrial fibrillations, especially in our patients that have had a cryptogenic stroke. They are higher cost and invasive, but higher yield in our select patients that are going to be higher risk or have not found any arrhythmias on a prior external cardiac monitor. Next are pacemakers and defibrillators that have atrial leads. These are not implanted for the intent of monitoring purposes, but if your patient has a device already, these can be an excellent monitoring tool. The wires, which are implanted directly into the heart in many instances, can detect and store episodes of AFib automatically. They can have long battery lives and can identify both symptomatic and subclinical atrial fibrillation. Handheld devices, so consumer devices, they're available on many platforms, like CardioMobile provide portable single lead ECGs that patients can use on demand. They are highly sensitive for atrial fibrillation. They're ideal for symptomatic patients or for frequent self-checks. They require patient engagement, some explaining as to how they work, a smartphone, and some interpretation guidance frequently is required. Smartwatches can use passive algorithms or on-demand single lead ECG to detect irregular rhythms. They're accessible, immediately available, non-invasive, and increasingly validated for AFib detection. False positives and reliance on user-initiated recordings are some limitations. So over the past decade, growing evidence has shown that increased and prolonged screening in at-risk individuals leads to higher detection of asymptomatic atrial fibrillation. The REHEARSE-AF trial used twice-weekly handheld ECGs, while REVEAL-AF employed implantable loop recorders, both in patients with stroke risk but no known atrial fibrillation. Each study demonstrated that more intensive and more continuous monitoring uncovers significantly more subclinical atrial fibrillation. However, despite this, current US task force and 2023 AFib guidelines stopped short of recommending routine population-wide screening due to uncertainty of the benefits of treating asymptomatic AFib, such as treating it with anticoagulation. And although validated risk prediction monitors can identify individuals at higher risk for developing AFib, it remains uncertain whether screening these patients and initiating interventions improves outcomes such as ischemic strokes, systolic embolism, or overall survival. These models are not routinely used in clinical practice, and the benefit of their application for screening remains unclear. The important exception to this is in patients with a history of stroke or systolic embolism. Studies like PERDIEM and CRYSTAL-AF have shown that implantable loop recorders in this group detect significantly more AFib compared to shorter-term monitoring. Given their higher risk of recurrent stroke, the guidelines give a class 2A recommendation for implantable loop recorder screening in this population, favoring it over external monitoring due to its increased sensitivity. A smartwatch can be used for the diagnosis of initial onset of AFib, but not for its optical feature or passive algorithms alone, as they're not reliable enough for definitive diagnosis. However, the ECG feature on some smartwatches has been found to be sufficiently accurate for the initial diagnosis of AFib, as long as a health care professional has reviewed the tracings. The initial diagnosis of AFib must be made by a health care professional who overreads ECG tracings, whether the tracing is from a consumer device, pacemaker, external monitor, or the gold standard, the 12-lead EKG. This and other consumer ECG devices can be used to monitor for AFib recurrence, as their ECG feature is considered reasonable for ongoing detection with a class 2A recommendation. Thank you.

atrial fibrillation

screening methods

implantable loop recorders

EKGs

smartwatches