Present state and future of screening for atrial fibrillation: a state-of-the-art review

Atrial fibrillation (AF) is the most common arrhythmia and is a leading cause of stroke and heart failure yet often remains undiagnosed. Screening has been proposed to identify asymptomatic AF and initiate preventive treatment, but evidence for reduction in hard clinical endpoints such as stroke and heart failure remains inconclusive. In this state-of-the-art review, we critically examine major AF screening trials across opportunistic, systematic and consumer-driven strategies, focusing on design features, population selection, monitoring strategies and outcomes. Variability in trial design, particularly in randomisation timing, participation rates and intensity of monitoring, significantly affects both AF detection and clinical outcomes. Systematic screening shows promise, but many trials were underpowered for hard outcomes. Opportunistic screening is easy to implement, but typically yields modest benefits, likely due to single timepoint assessments. Consumer-led, wearable-based screening shows high positive predictive value, but further evaluation in high-risk populations is needed. The success of AF screening hinges on reaching at-risk individuals and selecting effective monitoring strategies. Precision-based approaches and artificial intelligence-guided targeting may ensure that screening yields clinical and economical benefit.