ASSERT-III study

McIntyre WF et al.: Prevalence of undiagnosed atrial fibrillation in elderly individuals and potential cost-effectiveness of non-invasive ambulatory electrocardiographic screening: The ASSERT-III study. J Electrocardiol (2019) 58:56-60.
doi: 10.1016/j.jelectrocard.2019.11.040

In der kanadischen Studie wurde bei 100 Menschen im Alter von ≥80 Jahren (im Mittel 84±3 Jahre, CHADS-VASc-Score im Mittel 4.5) ein kontinuierliches EKG-Monitoring (Vitaphone 3100) über 30 Tage durchgeführt und optional um weitere 30 Tage verlängert, wenn kein Vorhofflimmern (VHF) registriert wurde. VHF ≥6 Min. wurde bei 14 %, ≥6 Std. bei 8 % und ≥24 Std. bei 3 % festgestellt. Eine Woche EKG-Monitoring verursachte Kosten von $ 50.000 pro „quality-adjusted life-year-gained“, 30 Tage bzw. 60 Tage verursachten entsprechend $ 70.000 bzw. $ 84.000.

BACKGROUND
In approximately 10% of patients with implanted pacemakers or defibrillators, previously unrecognized atrial fibrillation (AF) is detected within 3  months. It is unknown whether elderly patients without implanted devices have a similar prevalence of undiagnosed AF using non-invasive ECG monitoring, and if this approach to screening in this population is cost-effective.

METHODS
Individuals ≥80  years old attending outpatient clinics without a history of AF and with hypertension and one additional risk factor underwent 30  days of continuous ECG monitoring with an option for an additional 30 days of monitoring if no AF was detected. The primary outcome was AF ≥6 min. Cost-effectiveness to prevent stroke was estimated using a Morkov model based on observed AF detection rates and data from published literature.

RESULTS
Among 129 patients enrolled, 100 initiated monitoring for an average duration of 36 ± 21 days. The proportion of patients that completed at least 30 days of monitoring was 59%. Average age was 84 ± 3 years and mean CHA2DS2-VASc score was 4.5 ± 1.2. AF ≥ 6 min was documented in 14%, ≥6 h in 8%, and ≥24 h in 3%. One week of monitoring costed $50,000 per quality-adjusted life-year-gained, 30 days and 60 days of monitoring costed $70,000 and $84,000, respectively.

CONCLUSIONS
Continuous non-invasive ECG monitoring is feasible in elderly patients. Undiagnosed AF is present in many elderly individuals, with 1 in 7 having episodes lasting ≥6 min. One week of monitoring may be cost-effective for stroke prevention in this population.

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