Should we be targeting people with diabetes when screening for atrial fibrillation?

Br J Cardiol 2019;26(2)doi:10.5837/bjc.2019.014 Leave a comment
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First published online 11th April 2019

Atrial fibrillation (AF) and diabetes are chronic conditions, which are increasing in prevalence. Stroke is a recognised complication of both conditions and can often be prevented through detection and appropriate intervention. Screening for disease has also improved over the last few decades through a plethora of tools and advances in technology. AF impacts physically, psychologically, socially and economically, and does not always present with symptoms. AF can be detected through electrocardiogram (ECG) monitoring and pulse checks, with high-risk groups typically targeted. When AF is detected, medication to control heart rate and anticoagulation can be started to reduce subsequent risks. AF is underdiagnosed in the community, particularly in the elderly, and the condition lends itself to screening.1

A review of the evidence for AF screening demonstrates a lack of homogeneity, with different target populations. High-risk groups have varied and include those with hypertension, stroke, myocardial infarction, older age and diabetes. Although the pathophysiological relationship between AF and diabetes is not entirely understood, there is an acceptance that the coexistence imposes greater risk to the patient in terms of comorbidities including stroke.

Relationship between diabetes and AF

Mass screening of AF in the STROKESTOP study2 discovered diabetes, heart failure and previous stroke/transient ischaemic attack (TIA) to be the strongest predictors for AF in multi-variate analysis. This confirms findings from the historical Framingham study, where diabetes conferred a 1.4-fold increased risk of stroke in men and a 1.6-fold increased risk in women.3 A recent review of the evidence from AF screening studies in those with perceived high risks, has demonstrated the prevalence of AF in people with diabetes ranges from 2.9%4 to 18.5%.2 Chan and Choy’s study (2016)5 did not find diabetes to be a significant risk factor at univariate analysis, yet there was a positive link when analysed using a multi-variate method. Turakhia et al. (2015)6 revealed 8.3% of patients with diabetes in their study – using extended ambulatory monitoring – had AF. Davis et al. (2012)7 found a small number (<10%) of people with diabetes had AF, yet diabetes was shown to be more common in people with AF than in a normal rhythm (9% vs. 3.9%). Diabetes was strongly associated with higher prevalence of AF in both sexes (p<0.05) in a study by Sun et al. (2014),4 with age having the most significant impact on AF in their study. Diabetes was prevalent in 2.4% of males with AF (p=0.017, odds ratio [OR] 2.16) and 3.3% of females (p<0.001, OR 3.51).4

Further evidence has shown contradictory outcomes in terms of diabetes-associated AF, but overall prevalence is high. Krijthe et al. (2013)8 and Oldgren et al. (2014)9 conducted AF registries and concluded that while there was a high prevalence of AF in diabetes, this was not significant when age adjusted. A longitudinal prevalence study demonstrated that AF was up to 44% more prevalent when diabetes co-existed.10 A Belgian population screening programme for AF,11 which analysed five years of data from their Belgian heart rhythm screening week (n=65,747), identified 26.8% of people with diabetes having AF.

Ease of screening

AF lends itself to screening and diagnostic clarity through advancements in technology, and the availability of digital applications offers alternative, transportable and convenient methods for monitoring. Screening for AF continues to receive interest, with global campaigns striving to encourage mandatory screening in targeted groups. The diabetes population is accessible and can, therefore, be targeted during routine clinical reviews. A simple pulse check is an instant and available means of detecting an irregular pulse. This can be performed during the most basic of assessments. Single-lead ECG monitoring offers advantages in terms of rhythm recordings and can be used for either single point in time analysis or intermittent monitoring. And for optimal assessment, continuous ECG monitoring can be achieved through a number of applications, including Holter-style ECGs.

It is, therefore, evident that while there is a lack of research exploring the prevalence of AF in people with diabetes as a homogenous group, there is an association with a higher number of people with diabetes having AF than those without. Research into this as a targeted group is important and may then impact on public health, policy and potential screening of this population. However, before significant changes can be made, recommendations from the European Heart Rhythm Association (EHRA)12 would be advocated in terms of encouraging large experimental outcome studies to strengthen the evidence base. This high-risk group could then receive appropriate diagnosis, treatment and management and reduce the risk of costly and disabling complications, particularly stroke.

Conflicts of interest

None declared.


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