Screening for Atrial Fibrillation in Stroke Prevention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: Evidence is needed to determine the benefits and harms of screening for atrial fibrillation (AF) in stroke prevention. This meta-analysis aimed to evaluate the benefits and issues of AF screening among older adults.

Methods: This systematic review and meta-analysis were conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We systematically searched several databases from inception through 28 March 2025, selecting randomized controlled trials (RCTs) comparing AF screening, including systematic and opportunistic screening, versus routine practice or no screening. Two reviewers independently extracted the data and appraised the risks of bias of the studies.

Results: Thirteen articles covering 12 RCTs were included in the meta-analysis. For routine screening, systematic screening, rather than opportunistic screening, was more effective in detecting new AF cases (relative risk (RR), 2.07; 95% CI, 1.41 to 3.04; p = 0.0002). However, no difference was observed in the effectiveness of systematic and opportunistic screening in detecting AF (RR, 1.39; 95% CI, 0.59 to 3.30; p = 0.45). Compared with no screening, single-time-point screening did not improve the AF detection rate, whereas intermittent/continuous screening was associated with a greater likelihood of detecting AF (RR, 2.40; 95% CI, 1.59 to 3.64; p < 0.0001). There were no significant differences in the anticoagulation prescription rate between patients who underwent screening and routine care (RR, 1.16; 95% CI, 0.94 to 1.44; p = 0.16). Systematic screening was associated with a lower risk for the composite endpoint (combination of thrombosis-related events and mortality; RR, 0.96; 95% CI, 0.93 to 0.99; p = 0.02) but not for the individual endpoints. Compared with routine care, systematic screening did not increase the risk of major bleeding (RR, 0.88; 95% CI, 0.72 to 1.06; p = 0.18), whereas a positive screening result could promote anxiety.

Conclusions: Systematic screening outperformed routine care but was comparable to opportunistic screening in detecting undiagnosed AF. Systematic screening was related to a reduction in the composite endpoints of stroke and all-cause mortality without increasing the risk of bleeding.

Prospero registration: This systematic review was prospectively registered in PROSPERO, registration number: CRD42024558614, https://www.crd.york.ac.uk/PROSPERO/view/CRD42024558614.