Should all patients with atrial fibrillation be screened with echocardiography?
OBJECTIVE
To address a patient care problem suggested by a quality assurance study: Should physicians of patients with atrial fibrillation who have not had echocardiography performed be encouraged to obtain echocardiograms in order to discover heretofore undetected mitral stenosis, which could be treated with anticoagulation, in order to avert strokes?


METHODS
Decision analysis using a Markov-chain technique and quality-adjusted life expectancy.


METHODS
Outpatient clinics.


METHODS
Patients aged 40-80 years with chronic atrial fibrillation.


METHODS
The following strategies were studied: 1) obtain echocardiograms for all patients and anticoagulate those with mitral stenosis; 2) anticoagulate patients with classic auscultatory sounds of mitral stenosis and obtain echocardiograms for patients with other murmurs; if an echocardiogram reveals mitral stenosis, anticoagulate; 3) anticoagulate all patients with murmurs; 4) anticoagulate all patients; 5) observe all patients (natural history).


RESULTS
The base analysis, using data available in the literature and on site, indicated that though performing echocardiography on all patients with atrial fibrillation gave the best quality-adjusted life expectancy, the differences among the five strategies studied were small. In addition, sensitivity analysis revealed that the decision was sensitive to many of the variables used in the analysis, especially the efficacy and the risks of anticoagulation.


CONCLUSIONS
A recommendation that cardiac ultrasonography be done for all patients with atrial fibrillation in order to detect clinically unrecognized mitral stenosis cannot be made.
Desbiens
N A
NA
Department of Medicine, Marshfield Clinic, WI 54449.
D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications / Q000000981:diagnostic imaging*; D002543:Cerebral Hemorrhage / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D003661:Decision Support Techniques; D003663:Decision Trees; D004452:Echocardiography / Q000706:statistics & numerical data*; D006326:Heart Auscultation; D006801:Humans; D002542:Intracranial Embolism and Thrombosis / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D008875:Middle Aged; D012680:Sensitivity and Specificity; D015996:Survival Rate
D000925:Anticoagulants