Risk-based screening for the evaluation of atrial fibrillation in general practice (R-BEAT): a randomized cross-over trial

BACKGROUND: The optimal approach to the diagnosis of atrial fibrillation in primary care is unclear. AIM: To determine if external loop recorder (ELR) screening improves atrial fibrillation detection in community-dwelling adults with a CHA2DS2-VASc score of greater than two. DESIGN: Randomized cross-over clinical trial. METHODS: Community-dwelling adults ≥55 years with a CHA2DS2-VASc score of greater than two, who were deemed suitable for atrial fibrillation screening and oral anticoagulation by their general practitioner were randomly assigned to immediate or delayed ELR monitoring. The intervention period was ELR cardiac monitoring for 1 week and the usual care period was healthcare professional pulse screening and completion of electrocardiogram (ECG) or cardiac rhythm strip if pulse was identified as irregular. RESULTS: Of the 488 participants randomized, 244 were assigned to the immediate monitoring period (intervention) and 244 were assigned to the delayed monitoring period. Mean (SD) age was 75.0 (7.0) years and 333 participants were women (68%). Atrial fibrillation was detected in 32 of 488 participants (6.6%) in the intervention period versus five of 488 (1%) in the usual care period (absolute difference, 5.53% (3.2-7.9%), P < 0.001; number needed to screen 15 (11-23)). Twelve cases (37.5%) of ELR-detected atrial fibrillation were greater than 24 h in duration. Oral anticoagulation was initiated in all participants (n = 32). CONCLUSIONS: Among older community-dwelling adults with a CHA2DS2-VASc score of greater than two, screening with ELR for one week was associated with a 5.5% incremental detection of new atrial fibrillation over usual care. TRIAL REGISTRATION: ClinicalTrials.gov Register: NCT03911986.