Background: Early detection of atrial fibrillation(AF) may be associated with reduced complications and healthcare costs. Pts at risk of AF can be screened with portable EKG monitoring devices. AF risk can be identified from echocardiography but there is no systematic process for alerting physicians. We sought the value of echo-guided screening for paroxysmal AF.

Methods: A Markov decision-analysis model was created using data from published literature on costs/quality-adjusted life years(QALY) of two AF screening strategies in pts with a previous echo but without a cause for AF(eg. mitral valve disease, LV dysfunction):1)age based screening(AgeScreen;~3% detection rate)-EKG screening for ≥65 years,2)imaging-guided screening(ImagingScreen;~5% detection rate)-EKG screening for those with left atrial volume≥34ml/m² and LV global longitudinal strain(GLS)>-18%). Costs and effects were assessed for each strategy over a 20 year period. Base case -65-year-old man(CHA₂DS₂-VASC score 3) at risk of AF(hypertension and diabetes). The willingness-to-pay(WTP) threshold was $53,000/QALY gained.

Results: In the reference case an ImagingScreen approach(11.5 QALY, $56,604 cost/20 years) was more cost-effective than AgeScreen(11.52 QALY, $57,834/20 years). Monte Carlo simulation demonstrated that ImagingScreen was more cost-effective compared to AgeScreen, with observations more efficacious with cost below WTP(Figure). The main cost determinants were annual stroke/heart failure cost and AF detection rates. ImagingScreen was more cost-effective than AgeScreen across a range of annual stroke($24,000-$102,000)/heart failure($4,000-$12,000) costs. ImagingScreen was more cost-effective for AF detection rates up to 19%, after which AgeScreen became more cost-effective.

Conclusion: In pts with a previous echo, targeted AF screening to those with baseline clinical/imaging risk parameters is more cost-effective than age-based screening programs.