基层医疗中年龄≥65岁成人心房颤动机会性和系统性筛查：随机试验和整群随机试验的系统评价。
完整摘要 · 中文译文
目的：评估与常规诊疗相比，对≥65岁成人进行机会性房颤（AF）筛查是否提高房颤检出率并改善临床结局，并比较机会性与系统性筛查策略在房颤检出率和临床结局方面的差异。 方法：按照PRISMA 2020指南进行系统评价。纳入在≥65岁成人中评估机会性或系统性房颤筛查的随机和整群随机对照试验。检索电子数据库（MEDLINE、Embase和CENTRAL）从建库至2024年12月。将具有充分可比结局数据的研究纳入一项关于房颤检出率的结构化描述性定量综合分析。由于纳入研究之间存在显著的临床和方法学异质性，未进行合并meta分析；而是对研究层面的结局进行描述性总结。设计或结局报告存在异质性的研究采用叙述性综合。关注结局包括房颤检出、口服抗凝治疗的启动、卒中发生率和全因死亡率。采用Cochrane偏倚风险2.0工具评估偏倚风险。研究筛选和数据提取由两名评审员独立完成。 结果：共纳入9项随机或整群随机对照试验。与常规诊疗相比，机会性和系统性筛查策略均与既往未诊断房颤检出率增加相关。机会性筛查在多项试验中提高了房颤检出率； 然而，与系统性筛查方法的直接比较应谨慎解读，因为监测强度、随访时长和人群特征存在异质性。采用长时间或连续监测的研究通常得出更高的房颤检出率；然而，与机会性筛查的直接比较应谨慎解读，因为监测强度、随访时长和人群特征存在差异。抗凝治疗的启动在各研究间有所不同。在各研究中，未观察到卒中发生率或全因死亡率的持续降低。大多数试验被判定在偏倚风险方面存在一定问题，主要与实用性试验设计有关。由于房颤诊断均通过客观心电图标准确认，结局测量偏倚的风险总体较低。 结论：房颤筛查可提高老年人中既往未确诊房颤的检出率。机会性筛查可能比组织化系统性筛查项目更容易融入常规医疗就诊；然而，纳入试验并未一致评估实施结局和成本效益。当前随机证据未显示临床结局（如卒中减少或死亡率）的一致改善，这突出表明需要进一步开展高质量随机试验，评估整合筛查及检出后护理路径。
完整摘要 · 英文原文
OBJECTIVES: To evaluate whether opportunistic atrial fibrillation (AF) screening in adults aged ≥ 65 years improves AF detection and clinical outcomes compared with usual care, and to compare opportunistic and systematic screening strategies in terms of AF detection and clinical outcomes. METHODS: A systematic review was conducted in accordance with PRISMA 2020 guidelines. Randomized and cluster-randomized controlled trials evaluating opportunistic or systematic AF screening in adults aged ≥ 65 years were included. Electronic databases (MEDLINE, Embase, and CENTRAL) were searched from inception to December 2024. Studies with sufficiently comparable outcome data were included in a structured descriptive quantitative synthesis of AF detection rates. Because of substantial clinical and methodological heterogeneity among the included studies, a pooled meta-analysis was not performed. Instead, study-level outcomes were summarized descriptively. Studies with heterogeneous designs or outcome reporting were synthesized narratively. Outcomes of interest included AF detection, initiation of oral anticoagulation, stroke incidence, and all-cause mortality. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. Study selection and data extraction were performed independently by two reviewers. RESULTS: Nine randomized or cluster-randomized trials were included. Both opportunistic and systematic screening approaches were associated with increased detection of previously undiagnosed AF compared with usual care. Opportunistic screening increased AF detection in several trials; however, direct comparisons with systematic approaches should be interpreted cautiously because of heterogeneity in monitoring intensity, follow-up duration, and population characteristics. Studies employing prolonged or continuous monitoring generally yielded higher AF detection rates; however, direct comparisons with opportunistic screening should be interpreted cautiously because of differences in monitoring intensity, follow-up duration, and population characteristics. Anticoagulation initiation varied across studies. Across studies, no consistent reduction in stroke incidence or all-cause mortality was observed. Most trials were judged to have some concerns regarding risk of bias, primarily related to pragmatic trial designs. Because AF diagnosis was confirmed using objective electrocardiographic criteria, the risk of outcome measurement bias was generally low. CONCLUSION: AF screening increases detection of previously undiagnosed AF in older adults. Opportunistic screening may be more readily integrated into routine healthcare encounters than organized systematic screening programs; however, implementation outcomes and cost-effectiveness were not consistently evaluated across the included trials. Current randomized evidence does not demonstrate consistent improvement in clinical outcomes such as stroke reduction or mortality, highlighting the need for further high-quality randomized trials evaluating integrated screening and post-detection care pathways.