Baylor University Medical Center Proceedings July 2017 - 280

Review of screening studies for atrial fibrillation in rural
populations of 11 countries
Alex I. Gavino, MD, and Craig S. McLachlan, PhD, MPH&TM

Atrial fibrillation (AF) is a common cardiac arrhythmia, and pathological
burden can be influenced by environmental factors. The rural environment
may influence the burden of AF, although no systematic review studies
have been conducted to address this issue. We performed a systematic
review of AF screening studies conducted in rural global populations to
determine the burden, risk factors, and screening methods surrounding
AF in these settings. Out of the 1792 articles gathered from a keyword
search of medical databases and reference lists, 18 publications from
11 countries were included in our analysis. The pooled prevalence of AF
across the studies was 2.05% (95% confidence interval, 1.97%-2.13%)
and ranged from 0.3% to 10.87%. Only one study utilized a handheld
electrocardiogram to screen AF, while the rest used the 12-lead electrocardiogram. AF risk factors reported across studies varied and included
increasing age, male gender, hypertension, diabetes, prior myocardial
infarction or stroke, obesity, hyperlipidemia/hypercholesterolemia, alcohol
consumption, and heart failure. However, none of the studies assessed all
risk factors. We suggest that future research on AF in rural communities
examine a complete checklist of AF risk factors to better understand their
influence on AF burden and development. This will aid in understanding
rural prevention strategies and the management of detected AF cases
specific to rural areas. At present, the burden of AF in rural communities
is poorly understood and has been underreported.

actors speciﬁc to atrial ﬁbrillation (AF) risk are known
and include aging populations, poorer health status, and
possibly a higher prevalence of related cardiovascular risk
factors (1-3). Whether rural background is a risk factor
for AF prevalence has not been explored. There is an emerging
interest in improving the detection of AF in communities using
novel technologies (4). Screening for AF in rural communities
remains a challenge partly due to lack of access to services, as well
as limited knowledge of emerging screening devices and access to
automated software to detect AF. Location, demographics, and
socioeconomic circumstances (5) may contribute to the burden
of AF in rural communities. Detection rates for new cases of AF
in urban areas are improved if screening programs are in place for
AF screening (1.64%) compared to routine care (1.04%) (6). Additionally, AF detection in communities will also depend on the
type of screening utilized and the length of time the screening is
conducted. If screening is conducted over days as opposed to min280

utes or seconds, the diagnostic yield will be higher, particularly for
paroxysmal AF. Most reported data on AF screening programs are
based on epidemiological studies in urban populations (2, 7-13).
We performed a systematic review of literature for AF screening
to describe the methods used for AF detection in rural environments, to describe the risk factors included in these studies, and
to report on the overall global rural population prevalence of AF.
METHODS
Multiple databases (PubMed/MEDLINE, EMBASE,
Cumulative Index to Nursing and Allied Health Literature
[CINAHL], Scopus) were searched from inception through
March 15, 2016. Keywords for the search strategy included
(atrial ﬁbrillation) AND (screening OR detection OR diagnosis
OR identiﬁcation OR prevalence OR incidence) AND (rural
OR regional OR remote). In addition, we manually searched
reference lists, gray literature, and the Internet to ﬁnd other potential studies. We reviewed the titles and abstracts of retrieved
articles based on our predeﬁned selection criteria.
Inclusion criteria included a study design that was either a
cross-sectional population study or a prospective cohort. Additionally, the studies had to be conducted in a rural setting
and report AF prevalence. Studies were excluded if they 1) were
case-control studies or randomized controlled trials, 2) were
retrospective database reviews (i.e., electronic medical records,
general practice database, hospital records), 3) were conducted
in exclusively urban areas, or 4) measured AF prevalence among
participants with a speciﬁc comorbidity such as stroke, hypertension, obesity, or other cardiac diseases. The primary outcome
was the prevalence of AF in a general rural population. Secondary outcomes were AF risk factors and screening methods used.
After initial screening, full-text articles of potential studies were
obtained for further review. When we were unable to retrieve the
full text despite doing an exhaustive Internet search and contacting the authors, the studies were excluded. In a number of cases
From Rural Clinical School, Faculty of Medicine, University of New South Wales,
Sydney, Australia.
Corresponding author: Alex I. Gavino, MD, Rural Clinical School, Faculty of
Medicine, University of New South Wales, Samuels Building, Level 3, Sydney,
NSW 2052, Australia (e-mail: algavino@gmail.com; a.gavino@student.unsw.
edu.au; Twitter handle: @alexgavino).
Proc (Bayl Univ Med Cent) 2017;30(3):280-285

Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings July 2017