Searching for atrial fibrillation: looking harder, looking longer, and in increasingly sophisticated ways. An EHRA position paper

The current AF definition requires recording in classical ECG or Holter ECG at least a 30-s episode of AF. According to the current definition, the presence of frequent shorter episodes of fast atrial arrhythmia or episodes of arrhythmia identified with widely used screening tools requires subsequent steps to establish a definite diagnosis of AF. The use of different clinical risk scores can help to refine target populations better. Due to the unpredictable and highly variable nature of AF episodes, a monitoring time lasting 2 weeks or longer is preferable to maximize the possibility of identifying subjects with AF. Several capabilities are currently available for AF search/screening, including devices based on plethysmographic pulse assessment, belts and vests for long-term ECG monitoring, modern Holter capabilities, and ILRs. Decision-making regarding using particular of them should depend on proof of efficacy based on published data, patient characteristics, and purpose of monitoring (screening/search). Additionally, all subjects with CIED with the possibility of atrial sensing should be carefully evaluated to identify AHREs. In large-scale screening projects, ML and AI could provide the appropriate interpretation of large databases containing the results of a giant number of participants. From the patient perspective, participation in screening has positive but also negative aspects. Therefore, each patient should be able to accept or refuse to participate in a screening programme, being fully aware of the potential benefits or hurdles of the screening. As the first step of shared decision-making, identifying a patient’s values, goals, and preferences is mandatory.