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There isn't enough evidence to support ECG screening for atrial fibrillation (Afib) in asymptomatic adults ages 65 and older, according to a finalized recommendation statement from the U.S. Preventive Services Task Force (USPSTF).

The USPSTF assigned an "I" rating to such screening and concluded that "the current evidence is insufficient to assess the balance of benefits and harms of screening for Afib with ECG," said Susan Curry, PhD, of University of Iowa, Iowa City, and colleagues. Their recommendations were published online in and broadly follow the draft recommendations released in December 2017.

Additions and clarifications in response to public comments to the draft version included noting the REHEARSE-AF study, for example, and referencing the guidelines of the European Society of Cardiology.

While screening positive for Afib would put most older adults in line for anticoagulants, which have been proven effective for stroke prevention in symptomatic Afib, that benefit has not sufficiently been proven in asymptomatic Afib, Curry's group wrote. "At the same time, the harms of diagnostic follow-up and treatment prompted by abnormal ECG results are well established."

A cost analysis showed that if each ECG costs $100, the cost to prevent one stroke in people older than 75 years would be $1 million in ECGs alone, according to an editorial in by John Mandrola, MD, of Baptist Health Louisville, Kentucky, and colleagues who used data from the STROKESTOP study.

"If Afib screening is adopted in the absence of any outcomes data, hundreds of thousands, perhaps millions, of people will rightly and wrongly gain the diagnosis of a cardiac disorder," Mandrola's group wrote.

"Before turning this many people into patients, there should be compelling evidence that the benefits of this label exceed the harms, and that these benefits can be achieved at an acceptable cost," they argued, calling for randomized trials of Afib screening before its routine adoption.

"We can do better by first emphasizing a good basic physical examination with pulse palpation and cardiac auscultation, two low-cost Afib detection tools with excellent sensitivity when performed properly," according to Rod Passman, MD, MSCE, of Chicago's Northwestern Memorial Hospital, and Jonathan Piccini, MD, MHSc, of Duke Clinical Research Institute in Durham, North Carolina, in an accompanying editorial in .

It is also worthwhile to leverage advances in consumer electronics, including smartphones and smartwatches that already have Afib detection algorithms, to monitor at-risk patients over longer periods, they added. "However, these technologies will also have false-positive detection rates that will need to be addressed."

For now, the USPSTF has "correctly" emphasized the need for evidence to demonstrate that treatment of screening-detected Afib improves outcomes, said Jeffrey Goldberger, MD, and Raul Mitrani, MD, both of the University of Miami Miller School of Medicine in a viewpoint article in JAMA.

It is also important to reconsider the causal and temporal links between Afib and cardioembolic stroke, Goldberger and Mitrani argued. "Specifically, it is now clear that although Afib and Afib burden are likely causally linked to cardioembolic stroke in some patients with Afib, this association is not causal in a substantial number of patients."

And that means that primary prevention of Afib-associated stroke may need to expand beyond even ECG screening, they added.