Opportunistic and systematic screening for atrial fibrillation in adults aged ≥ 65 years in primary care: a systematic review of randomized and cluster randomized trials.
Mansour M, Hussein M, Foda M • BMC cardiovascular disorders • 2026
AF screening increases detection of previously undiagnosed AF in older adults, but current randomized evidence does not demonstrate consistent improvement in clinical outcomes such as stroke reduction or mortality.
Key Findings
Results
Both opportunistic and systematic AF screening approaches were associated with increased detection of previously undiagnosed AF compared with usual care.
Nine randomized or cluster-randomized trials were included in the systematic review.
Studies were identified through searches of MEDLINE, Embase, and CENTRAL from inception to December 2024.
The review followed PRISMA 2020 guidelines with independent study selection and data extraction by two reviewers.
Because of substantial clinical and methodological heterogeneity, a pooled meta-analysis was not performed; outcomes were summarized descriptively.
Results
Studies employing prolonged or continuous monitoring generally yielded higher AF detection rates than shorter monitoring approaches.
Direct comparisons between monitoring intensities should be interpreted cautiously because of differences in monitoring intensity, follow-up duration, and population characteristics.
This pattern was observed across the descriptive synthesis of AF detection rates from the included trials.
Heterogeneity in monitoring strategies was identified as a key source of variability across studies.
Results
Anticoagulation initiation varied across studies without a consistent pattern.
Initiation of oral anticoagulation was one of the pre-specified outcomes of interest.
No consistent summary statistic for anticoagulation initiation could be derived due to heterogeneity in study designs and outcome reporting.
Studies with heterogeneous designs or outcome reporting were synthesized narratively rather than quantitatively.
Results
No consistent reduction in stroke incidence or all-cause mortality was observed across the included AF screening trials.
Stroke incidence and all-cause mortality were pre-specified outcomes of interest.
Current randomized evidence does not demonstrate consistent improvement in these clinical outcomes.
The authors highlight this as evidence of 'the need for further high-quality randomized trials evaluating integrated screening and post-detection care pathways.'
Nine trials were reviewed and none individually or collectively demonstrated consistent benefit on these hard clinical endpoints.
Results
Most trials were judged to have some concerns regarding risk of bias, primarily related to pragmatic trial designs.
Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool.
Because AF diagnosis was confirmed using objective electrocardiographic criteria, the risk of outcome measurement bias was generally low.
Pragmatic trial designs were identified as the primary source of bias concerns.
Conclusions
Opportunistic screening may be more readily integrated into routine healthcare encounters than organized systematic screening programs.
Implementation outcomes and cost-effectiveness were not consistently evaluated across the included trials.
Opportunistic screening increased AF detection in several trials, but direct comparisons with systematic approaches should be interpreted cautiously.
Heterogeneity in monitoring intensity, follow-up duration, and population characteristics limited direct comparisons between screening strategies.
The included population was adults aged ≥65 years in primary care settings.
What This Means
This research synthesized evidence from nine randomized clinical trials to evaluate whether screening older adults (aged 65 and over) for atrial fibrillation (AF) — an irregular heart rhythm that increases stroke risk — leads to better health outcomes. Two main screening approaches were compared: 'opportunistic' screening, where patients are checked for AF during routine healthcare visits, and 'systematic' screening, where organized programs actively seek out undiagnosed cases. Both approaches successfully identified more cases of previously undiagnosed AF compared to standard care, with longer or continuous heart monitoring tending to find more cases than shorter checks.
However, despite detecting more AF, the trials did not show a consistent reduction in strokes or deaths among screened patients. This is a critical gap, because the main reason to screen for AF is to start blood-thinning medications (anticoagulants) that reduce stroke risk — yet the studies showed variable rates of anticoagulation initiation and no clear downstream benefit on hard health outcomes. The researchers also found that opportunistic screening may be easier to implement in everyday clinical practice than organized systematic programs, though cost-effectiveness was rarely assessed in the included studies.
This research suggests that while AF screening can find more cases of this common heart condition in older adults, simply detecting AF is not enough on its own to improve health outcomes. Future studies need to examine not just whether screening finds AF, but whether the full chain of care — from detection through treatment and follow-up — actually prevents strokes and saves lives. These findings are relevant to healthcare providers and policymakers considering how to structure AF screening programs for older populations.
Mansour M, Hussein M, Foda M. (2026). Opportunistic and systematic screening for atrial fibrillation in adults aged ≥ 65 years in primary care: a systematic review of randomized and cluster randomized trials.. BMC cardiovascular disorders. https://doi.org/10.1186/s12872-026-06253-2