Atrial Fibrillation Screening in Those with Rheumatic Heart Disease: A Narrative Policy Content Review

Search strategy

A comprehensive literature search was conducted in May 2025 across multiple data sources to identify relevant national/international clinical guidelines and policy documents addressing AF screening in patients with RHD. Major biomedical databases (PubMed, MEDLINE and Scopus), were searched to capture peer-reviewed literature. In parallel, manual searches of other sources were conducted by reviewing the official websites of leading international and regional cardiovascular organisations, such as the World Health Organization (WHO), World Heart Federation (WHF), ESC, Asia Pacific Heart Rhythm Society (APHRS) and national cardiac and public health authorities (e.g., Communicable Diseases Network, Australia). Reference lists of key publications were manually screened to identify additional relevant documents.

The search strategy employed a combination of controlled vocabulary (e.g., MeSH terms) and free-text keywords, using Boolean operators to maximise search sensitivity. Core search terms included: ‘atrial fibrillation’, ‘rheumatic heart disease’, ‘screening’, ‘policy’, ‘guideline’, ‘recommendation’, ‘consensus statement’ and ‘position paper.’ The search targeted both AF-specific and RHD-specific guidelines, as well as broader cardiovascular policy documents that might contain relevant screening recommendations for high-risk populations.

Inclusion and exclusion criteria

Documents were included if they met the following criteria:

1. They were official policy documents, guidelines, position papers or consensus statements published or endorsed by professional societies, expert groups or government bodies;

2. The content explicitly addressed AF or RHD, or both;

3. Were relatively recent (defined as published after 2010); and

4. The document was the most current version available when the search was conducted.

Exclusion criteria were: outdated versions, duplicate publications, non-official editorials, news articles, non-English language documents and commentaries lacking formal endorsement.

AF-focussed guidelines: Higher-risk groups mainly based on age

Among the 16 AF-focussed policy and guideline documents reviewed, all but two supported some form of AF screening (systematic and/or opportunistic screening; Table 1), typically in well-defined higher-risk populations such as older adults or individuals with comorbidities or symptoms (19). For example, the 2024 ESC guidelines recommend opportunistic screening (e.g., pulse palpation or single lead ECG) for individuals aged ≥65 years and consideration of systematic ECG screening for those aged ≥75 years or at elevated stroke risk (11). Rather than relying on age, the UK National Institute for Health and Care Excellence (NICE) recommends pulse palpation ‘if there is a suspicion of AF’, for example, in people presenting with breathlessness, palpitations, syncope, dizziness, chest pain, stroke or transient ischaemic attack (20).

The two documents that did not recommend AF screening in the general population were the US Preventive Services Task Force (USPSTF) and the 2023 American College of Cardiology (ACC)/American Heart Association (AHA) guideline. The USPSTF found that current evidence is ‘insufficient to assess the balance of harms of screening for AF’ (‘I statement’), and the ACC/AHA concluded that there was insufficient evidence of benefit from screening (21).

Nine of the 16 documents mention RHD, but typically only in the context of broader discussions on valvular heart disease or anticoagulation therapy. In most cases, RHD is used to help define ‘valvular AF’, which carries a distinct thromboembolic risk profile and influences anticoagulation strategy. However, these documents do not recognise RHD patients as a subgroup warranting specific AF screening strategies. The notable exception is the 2021 APHRS consensus guidance, which was developed with explicit consideration of regions where RHD remains endemic. It is the only AF practice guidance to directly recommend screening in patients with RHD.

RHD-focussed guidelines: AF recognised as a complication

Among the 13 RHD-focussed guideline and policy documents reviewed, AF was most commonly discussed as a complication of advanced valvular disease (Table 2). While 10 of the documents explicitly mentioned AF in the context of RHD, such references were typically brief and embedded within broader discussions of chronic disease complications or anticoagulation. Notably, none of the guidelines reviewed recommend screening for AF in patients with RHD, even though several recognise the elevated thromboembolic risk associated with valvular AF.

In the 2024 WHO guideline, AF is listed among the major complications of symptomatic chronic RHD, alongside heart failure, stroke and endocarditis. The document advises that these conditions ‘should be managed using standard protocols, including anticoagulation where indicated (e.g., AF, mechanical valve)’, but offers no additional detail on detection or timing of intervention (2). Similarly, the New Zealand 2024 guideline identifies AF as one of several complications that may prompt the diagnosis of RHD in adulthood and includes AF in its management considerations for long-term follow-up and pregnancy, though without specifying detection strategies or thresholds for intervention (32).

Some national and regional guidelines from low- and middle-income settings, including Fiji (33), Kenya (34) and Sudan (35), recommend anticoagulation for patients with known AF and RHD. For instance, the Fiji guideline recommends long-term anticoagulation in ‘all patients with AF and valvular heart disease’, referring clinicians to cardiovascular disease guidelines for further AF management (33). The Sudan guideline lists AF as a high-risk condition in RHD patients that warrants intensified anticoagulation, grouping it with mitral stenosis, prior thromboembolism and reduced ejection fraction (35).

Among the highest resource environments, the most comprehensive set of recommendations on managing AF in RHD is available in Australia’s 2025 national RHD guideline (36). It includes specific indications for anticoagulation in patients with AF and rheumatic mitral stenosis, references the INVICTUS trial results in guiding agent selection, and discusses anticoagulation in patients in sinus rhythm with enlarged left atria or prior embolic events. However, despite this depth, the Australian guideline does not advocate for routine or opportunistic screening for AF in RHD populations.

In contrast, several older documents, such as the Western Cape (2003) and India’s 2015 handbook, do not mention AF at all (37, 38). The 2018 WHO RHD policy report similarly omits AF, focussing instead on primary and secondary prevention of acute rheumatic fever and structural heart disease (39).

Across all RHD focussed-documents, discussion of AF is largely confined to treatment pathways initiated after clinical detection. There is no mention of asymptomatic or subclinical AF, nor guidance on when or how to assess for arrhythmias during routine RHD follow-up. While AF is increasingly recognised in newer guidelines as an important driver of morbidity – particularly through its association with stroke and heart failure – none of the RHD documents specifically incorporate AF screening recommendations for those with RHD.

AF screening recommendations in those with RHD

The only document that includes specific AF screening recommendations for those with RHD is the APHRS 2021 AF screening practice guidance (15). One of the most important contributions of the APHRS practice guidance is its explicit acknowledgement of RHD as one of the major causes of AF in LMICs. While the incidence of RHD has sharply declined in Western populations, it remains endemic in much of the Asia-Pacific and among Indigenous populations in Australia and New Zealand. Approximately 73% of global RHD cases are concentrated in five countries: India, China, Pakistan, Indonesia and the Democratic Republic of Congo (44). AF linked to RHD tends to occur at younger ages and carries a significantly elevated risk of thromboembolic events, particularly stroke. The APHRS document directly addresses this, offering the first structured, regionally contextualised policy framework for screening in this high-risk population.

To support implementation across diverse healthcare systems, the APHRS document has a pragmatic, three-tiered recommendation model according to national health resources. The levels of recommendation are: Level 1 (applicable to all countries), Level 2 (most countries) and Level 3 (some countries with higher resources). Within this framework, the guidance defines clear clinical indicators for prioritising RHD patients for screening. AF screening is recommended for RHD patients aged >50 years (all countries) and higher-risk RHD patients (most countries). ‘Higher risk’ RHD patients include those with NYHA class II or greater functional impairment, as well as those with echocardiographic markers of disease severity, including left atrial enlargement (>4.0 cm), mitral valve area <1.0 cm², mitral calcification, or a mitral valve gradient >10 mmHg. Such stratification provides operationally feasible and clinically relevant means of selecting RHD patients at the highest risk of developing AF. The guidelines suggest numerous options for screening methods, including pulse palpation, handheld single-lead ECGs, automated blood pressure monitors with software for detecting AF, and smartphone applications based on photoplethysmography (PPG). Diagnosis requires ECG verification (single or 12-lead), and a pathway to management and treatment with anticoagulation for those at high stroke risk.

There are a number of theoretical benefits of recommending AF screening for patients with RHD. Patients with RHD are more likely to develop AF at a younger age and with a higher risk (16). They are also more likely to present late and are frequently from LMICs, where RHD is more prevalent (14). Screening benefits in this group could include improved clinical outcomes from early detection and treatment and improved resource allocation and reduced health system burden from stroke prevention. There is also an important health equity argument in favour of improved screening and prevention in this patient population.

Possible reasons for the lack of prioritising RHD

RHD does not receive a sufficiently high level of global priority. A recent review identified several reasons for this: (1) leadership and governance: RHD mainly affects low income groups in dispersed regions, making coordination of efforts more complicated; (2) solution definition: lack of agreement as to how best to address RHD; and (3) positioning: the perception of RHD as being mainly a problem for LMICs and ambiguity of its status as a noncommunicable disease have impeded action by policy makers (45). Another paper by Belay and Aliyu states bluntly that RHD is ‘missing from the global health agenda’ (46). The authors highlight a number of reasons, including underestimated morbidity, mortality and economic burden, lack of awareness and lack of sustainable investment.

In the context of AF screening policies, one other reason for a lack of inclusion of RHD is gaps in the evidence. While the APRHS practice guidance notes evidence of some predictors of AF in RHD [e.g., age >50 years (47), left atrial diameter >4.0 cm on echocardiogram (48), mitral valve calcification (49) and severity of mitral valve stenosis (50)], it also points out that more evidence is needed about risk factors in this population (15). A recent meta-analysis showed that the main factors associated with AF in those with RHD include age, mitral valve disease, especially with associated tricuspid involvement, left atrium enlargement, right atrium pressure and systolic pulmonary arterial pressure (14). The authors also noted that the development of a predictive tool to help identify patients at the highest risk for developing AF would be helpful in the RHD population (14).

Health system impact and implications

In patients with RHD, particularly those with rheumatic mitral stenosis, the presence of AF acts as a profound risk multiplier, increasing the risk of stroke by up to 17-fold (51). The clinical benefit of early intervention is exceptionally high. The number needed to treat (NNT) to prevent one major stroke over a single year is estimated at only 12 to 15 patients (52, 53). Beyond ischemic stroke, undetected AF in RHD rapidly accelerates the progression of severe heart failure and increases the risk of systemic embolization, frequently precipitating life-threatening cardiovascular crises. Furthermore, RHD-associated AF predominantly affects a younger demographic, frequently developing in patients in their 30s to 50s (54). Consequently, there is a high economic cost, driven by the direct upfront costs to health systems, and also by the loss of prime productivity.

Our study reveals a major deficit in recommendations for AF screening among RHD populations, highlighting significant gaps in current health policies and clinical guidelines. While the observed absence of formal recommendations likely reflects the lack of studies in this scenario, we believe that this is itself a notable finding warranting attention. We advocate for clinical steering committees and peak cardiovascular bodies to formally incorporate explicit recommendations for the early, opportunistic detection of AF within RHD guidelines. At minimum, this could serve to raise awareness and position AF screening in those with RHD as a research priority. Studies evaluating screening programmes must consider the expected downstream implications, including existing healthcare infrastructure, workforce capacity and pathway/access to AF treatment (55). The proposed screening modality and frequency should be tailored to the specific population and setting. For example, depending on factors such as rural or urban population, existing digital health infrastructure and remote transmission capability, there are options such as handheld devices capable of storing ECG tracings or continuous monitors with simultaneous remote transmission (56). Studies evaluating screening interventions should ideally quantify benefits and harms, establish cost-effectiveness and investigate the feasibility and acceptability among patients and healthcare workers (57, 58, 59).

In LMICs and remote settings, implementing screening protocols often requires the strategic empowerment of community health workers, nurses and rural generalists through upskilling to conduct initial screenings and manage ongoing care. A realistic framework must account for the scarcity of specialists, cost and availability of oral anticoagulation and geographic distances (60). To overcome these barriers, screening models may leverage mobile health technology and local capacity building. The integration of point-of-care diagnostics, nurse-led AF clinics, multidisciplinary care teams and telemedicine support can substantially improve AF-related outcomes (61).

Strengths and limitations

Strengths of this review include the comprehensive nature of the document search and the inclusion of both AF-focussed and RHD-focussed guidelines across a range of geographic and health system contexts.

However, several limitations must be acknowledged. First, the review was limited to English-language policy documents and those accessible through publicly available databases or organisational websites, potentially excluding unpublished or locally adapted documents from low-resource settings. Secondly, as a narrative review, there is an inherent risk of subjectivity in interpretation and synthesis, although data extraction was standardised to reduce bias.