TYPE Original Research PUBLISHED 15 February 2023 DOI 10.3389/fcvm.2023.1112561 General practitioners’ perceptions OPEN ACCESS on opportunistic single-time point screening for atrial fibrillation: A EDITED BY Michael Brunner, Artemed Kliniken Freiburg, St. Josefskrankenhaus, Germany European quantitative survey REVIEWED BY Jacqueline Joza, McGill University Health Centre, Paulien Vermunicht 1,2*, Mihaela Grecu 3, Jean-Claude Deharo 4, Canada Claire M. Buckley 5, Elena Palà 6, Georges H. Mairesse 7, Tchavdar Shalganov, National Heart Hospital, Michal M. Farkowski 8, Marco Bergonti 1,2, Helmut Pürerfellner 9, Bulgaria Coral L. Hanson 10, Lis Neubeck 10, Ben Freedman 11,12, Henning Witt 13, *CORRESPONDENCE Paulien Vermunicht Mellanie T. Hills 14, Jenny Lund 15, Katrina Giskes 11,16, Daniel Engler 17,18, Paulien.Vermunicht@uantwerpen.be Renate B. Schnabel 17,18, Hein Heidbuchel 1,2,19, Lien Desteghe 1,2,19,20 SPECIALTY SECTION for the AFFECT-EU investigators This article was submitted to Cardiac Rhythmology, 1 Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium, 2 Research Group Cardiovascular a section of the journal Diseases, University of Antwerp, Antwerp, Belgium, 3 Electrophysiology Department, Cardiovascular Diseases Frontiers in Cardiovascular Medicine Institute, Iasi, Romania, 4Assistance Publique − Hôpitaux de Marseille and Aix Marseille Université, C2VN, RECEIVED 30 November 2022 Marseille, France, 5 School of Public Health, University College Cork, Cork, Ireland, 6 Neurovascular Research ACCEPTED 25 January 2023 Laboratory, Vall d’Hebron Institute of Research (VHIR) - Universitat Autónoma de Barcelona, Barcelona, PUBLISHED 15 February 2023 Spain, 7 Cliniques du Sud Luxembourg, Arlon, Belgium, 8 II Department of Heart Arrhythmia, National Institute of Cardiology, Warszawa, Poland, 9 Department of Cardiology, Ordensklinikum Linz Elisabethinen, Linz, CITATION Austria, 10 School of Health and Social Care, Edinburgh Napier University, Edinburgh, United Kingdom, Vermunicht P, Grecu M, Deharo J-C, 11 Heart Research Institute, The University of Sydney, Sydney, NSW, Australia, 12 Charles Perkins Centre and Buckley CM, Palà E, Mairesse GH, Concord Hospital Cardiology, The University of Sydney, Sydney, NSW, Australia, 13 Pfizer Pharma GmbH, Farkowski MM, Bergonti M, Pürerfellner H, Berlin, Germany, 14 StopAfib.org, Dallas, TX, United States, 15 Primary Care Unit, Department of Public Health Hanson CL, Neubeck L, Freedman B, Witt H, and Primary Care, University of Cambridge, Cambridge, United Kingdom, 16 Department of General Practice, Hills MT, Lund J, Giskes K, Engler D, School of Medicine, University of Notre Dame, Sydney, NSW, Australia, 17 Department of Cardiology, Schnabel RB, Heidbuchel H, Desteghe L and for University Heart and Vascular Center Hamburg Eppendorf, Hamburg, Germany, 18 German Center for the AFFECT-EU investigators (2023) General Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany, 19 Faculty of practitioners’ perceptions on opportunistic Medicine and Life Science, Hasselt University, Hasselt, Belgium, 20 Heart Center Hasselt, Jessa Hospital, single-time point screening for atrial fibrillation: Hasselt, Belgium A European quantitative survey. Front. Cardiovasc. Med. 10:1112561. doi: 10.3389/fcvm.2023.1112561 COPYRIGHT Background: There is no clear guidance on how to implement opportunistic atrial © 2023 Vermunicht, Grecu, Deharo, Buckley, Palà, Mairesse, Farkowski, Bergonti, fibrillation (AF) screening in daily clinical practice. Pürerfellner, Hanson, Neubeck, Freedman, Witt, Objectives: This study evaluated the perception of general practitioners (GPs) about Hills, Lund, Giskes, Engler, Schnabel, Heidbuchel, Desteghe and for the AFFECT-EU value and practicalities of implementing screening for AF, focusing on opportunistic investigators. This is an open-access article single-time point screening with a single-lead electrocardiogram (ECG) device. distributed under the terms of the Creative Commons Attribution License (CC BY). The Methods: A descriptive cross-sectional study was conducted with a survey developed use, distribution or reproduction in other to assess overall perception concerning AF screening, feasibility of opportunistic forums is permitted, provided the original single-lead ECG screening and implementation requirements and barriers. author(s) and the copyright owner(s) are credited and that the original publication in this Results: A total of 659 responses were collected (36.1% Eastern, 33.4% Western, 12.1% journal is cited, in accordance with accepted Southern, 10.0% Northern Europe, 8.3% United Kingdom & Ireland). The perceived academic practice. No use, distribution or reproduction is permitted which does not need for standardized AF screening was rated as 82.7 on a scale from 0 to 100. The comply with these terms. vast majority (88.0%) indicated no AF screening program is established in their region. Three out of four GPs (72.1%, lowest in Eastern and Southern Europe) were equipped with a 12-lead ECG, while a single-lead ECG was less common (10.8%, highest in United Kingdom & Ireland). Three in five GPs (59.3%) feel confident ruling out AF on a single-lead ECG strip. Assistance through more education (28.7%) and a tele- healthcare service offering advice on ambiguous tracings (25.2%) would be helpful. Preferred strategies to overcome barriers like insufficient (qualified) staff, included integrating AF screening with other healthcare programs (24.9%) and algorithms to identify patients most suitable for AF screening (24.3%). Frontiers in Cardiovascular Medicine 01 frontiersin.org Vermunicht et al. 10.3389/fcvm.2023.1112561 Conclusion: GPs perceive a strong need for a standardized AF screening approach. Additional resources may be required to have it widely adopted into clinical practice. KEYWORDS atrial fibrillation, screening, AFFECT-EU, survey, general practitioners 1. Introduction 2.2. Target audience The prevalence of atrial fibrillation (AF), currently 2–4%, will Given the results of the previously performed qualitative study, the increase further worldwide in the next decades (1). Although AF target audience to complete this survey consisted of GPs (6). episodes are commonly accompanied by symptoms, episodes occur Nevertheless, other relevant primary healthcare professionals, such as asymptomatically in one patient in three (2). Nevertheless, asymptomatic nurses and scientists (n = 38), were not excluded. In contrast, some patients are at increased risk of stroke, other cardiovascular responses of secondary care based physicians, i.e., cardiologists and complications, and death, comparable to symptomatic patients. With geriatricians (n = 10), were excluded from analysis. timely AF diagnosis, oral anticoagulant therapy can reduce the stroke risk with >60% (3). The increasing prevalence, the risk of asymptomatic AF and the increasing availability of AF detection tools, have fueled 2.3. Dissemination international interest in AF screening methods (4). The European Society of Cardiology (ESC) AF guidelines The survey was implemented electronically via Qualtrics (Provo, recommend opportunistic AF screening by pulse taking or Utah, United States) and could be accessed via a weblink. The electrocardiogram (ECG) rhythm strip in patients ≥65 years (5). Despite dissemination was performed by firstly contacting European GP these recommendations, the optimal setting with the highest efficiency organizations. In a second phase, also personal GP networks within the for implementation in daily clinical practice remains uncertain among AFFECT-EU consortium and beyond were contacted. To reduce the experts (4). possible impact of language barriers, the survey was made available in A prior European qualitative study of the AFFECT-EU project was Dutch, German, Spanish, French, Italian, Polish and Romanian, in conducted in which regulators and healthcare professionals with addition to English (language choice was made before respondents gave expertise in (AF) screening pathways were interviewed on the feasibility their consent to participate). Responses were collected between July and challenges of implementing different AF screening scenarios. The 2021 and May 2022. Ethics approval was granted by Ethik-Kommission experts considered single-time point opportunistic screening in primary der Ärztekammer Hamburg. care using single-lead ECG devices as the most feasible approach to screen for AF (6). However, information on the opinion of general practitioners (GPs) remains largely unknown. 2.4. Statistics The aim of this study was to evaluate the overall perception of GPs in Europe concerning the value and practicality of implementing AF The response data were downloaded in Microsoft Excel and further screening in daily clinical practice, focusing on opportunistic single- analyzes occurred in SPSS (version 28.0, IBM, NY, United States). time point screening with a single-lead ECG device. The results provide Descriptive statistics were used to analyze the responses. Countries insight into the general and region-specific opportunities and obstacles were classified into European subregions using the United Nations for implementation of AF screening at scale. In addition, this study (UN) Geoscheme. Although the UN Geoscheme is the most commonly identified the preferred strategies to overcome screening-related used scheme to divide European countries into geographical regions, it barriers. may not reflect the differences between health care systems in countries. According to the scheme, United Kingdom & Ireland are counted as part of Northern Europe. However, due to known differences in health 2. Methods system, United Kingdom & Ireland were considered a separate sub-region in this study. To check whether two categorical variables 2.1. Survey were associated, the chi-square test was applied. The Kruskal Wallis test assessed whether the medians of different European regions were equal. A European, descriptive, cross-sectional study was conducted with Results were considered significant for p-values <0.05. a specifically developed survey (Supplementary annex 1). The survey was designed by the coordinating investigators and consisted of four different parts: (i) general demographic characteristics of the 3. Results respondents, (ii) overall availability and perception of screening approaches for AF and other conditions, (iii) feasibility of opportunistic 3.1. Demography of the respondents single-time point screening with a single-lead ECG device, and (iv) possible requirements and barriers for the implementation of AF A total of 596 respondents completed all four parts of the survey. A screening. The survey was validated for its content further 16 and 47 responses were included from participants who (Supplementary annex 2) and took approximately 5–7 min to complete. completed the survey up to part two and part three, respectively, Frontiers in Cardiovascular Medicine 02 frontiersin.org Vermunicht et al. 10.3389/fcvm.2023.1112561 leading to a total of 659 responses. The respondents had a mean age of than for colon cancer (87.2), breast cancer (87.7), diabetes (88.2), high 50.2 ± 12.1 years. 94.2% of them were GPs, 3.0% nurses, 2.1% allied blood pressure (89.1) and cervical cancer (89.7) (Figure 3). There was healthcare professionals and 0.6% scientists/occupational physicians. less variation within Eastern Europe compared to the other regions, with Responses were collected from 18 different European countries this region attaching great importance to screening for all mentioned (Figure 1), with the majority from Eastern Europe (36.1%), followed by conditions (Supplementary Table 2). Western Europe (33.4%), Southern Europe (12.1%), Northern Europe (10.0%) and United Kingdom & Ireland (8.3%). It is important to note 3.2.2. Availability of ECG devices that Eastern Europe is mainly represented by Romania (87.4% of Almost three in four respondents (72.1%) had a 12-lead ECG Eastern European respondents). Results for the subregions separately device available in their practice, while a single-lead ECG device was can be found in the Supplementary Tables. less common (10.8%). In addition, 6.5% had a 3-lead device, 3.2% had another ECG device (e.g., 15-lead, 6-lead) and 19.1% had no ECG device available. Notable regional differences were found between the 3.2. Overall perceptions concerning AF availability of a 12-lead device (p < 0.001) and a single-lead device screening and screening approaches in (p < 0.001) (Supplementary Table 3). The majority of GPs had a 12-lead general ECG device in Northern Europe (98.5%), United Kingdom & Ireland (92.7%) and Western Europe (81.4%), while the availability of such a 3.2.1. Presence of and perceived need for device was lowest in Southern (65.0%) and Eastern (53.8%) Europe. A screening approaches for AF and other conditions single-lead device was fairly common in United Kingdom & Ireland Of all respondents, 12% indicated that an AF screening program (63.6%), but far less prevalent in other parts of Europe (1.5–7.1%). was established in their region. Standardized screening was more often implemented for other conditions such as colon (70.7%), breast (81.9%) 3.2.3. Regular health checks in patients over and cervical (87.1%) cancers (Figure 2). The presence of various 65 years old screening approaches, including AF screening (p = 0.019), differed When asked which general health checks the GPs would do if a between the European regions (Supplementary Table 1). In both patient ≥65 years comes to their practice, blood pressure check (89.4%) Southern Europe and United Kingdom & Ireland, 20.0% indicated that and pulse check (79.5%) were most frequently performed. In contrast, they applied some form of AF screening, while this was less in other only 11.7 and 6.1% would perform a rhythm check with a 12-lead ECG regions (7.6–11.8%). and a single-lead ECG device, respectively (Figure 4). A check with a The need for standardized AF screening was rated as 82.7 on a scale single-lead device was carried out significantly different in the European from 0 to 100, which was higher than for prostate cancer (73.2), a regions (p < 0.001) and more often in United Kingdom & Ireland (36.4%) general health check-up (75.3) and elevated cholesterol (79.4), and lower compared to the other regions (0–4.6%) (Supplementary Table 4). FIGURE 1 Origin of the respondents. Country groups are based on The United Nations Geoscheme, except for the UK and Ireland which were considered a separate sub-region due to the difference in health system. Frontiers in Cardiovascular Medicine 03 frontiersin.org Vermunicht et al. 10.3389/fcvm.2023.1112561 3.3. Feasibility of opportunistic single-time Overall, 28.7% of GPs indicated that more education on ECG and point AF screening with a single-lead ECG smarter ECG devices would improve their confidence. Moreover, 25.2% device perceived a tele-healthcare service for upload of ECG tracings and rapid advice as helpful, and 23.4% would consider a standardized Three in five respondents (59.3%) indicated that they would feel follow-up pathway with the possibility of a quick referral to the fairly or completely confident to rule out AF on a 30 s single-lead ECG cardiologist of added value. The preferred assistance for each region can strip. Others felt either somewhat confident (19.6%), slightly confident be found in Supplementary Table 6. About one GP in five (18.0%) (9.0%) or not confident (12.1%). The confidence level was highest in indicated they did not need external help to rule out AF on a single- United Kingdom & Ireland, where 85.4% were completely or fairly lead ECG tracing. confident, followed by 76.9% in Southern, 60.6% in Northern, 58.2% in Western and 47.6% in Eastern Europe (p-values for fairly and completely confident were 0.010 and < 0.001, respectively) 3.4. Requirements and barriers for the (Supplementary Table 5). implementation of opportunistic single-time point AF screening with a single-lead ECG device One third (32.2%) indicated that they could easily start conducting AF screening or have already implemented it. For others, barriers to implementing opportunistic single-time point AF screening with a single-lead device were diverse (Table 1). The most important ones were lack of education (18.2%), and insufficient (qualified) staff and ECG devices (18.5%). The need for more education varied per region (p < 0.001) and was the highest in Eastern Europe (29.0%) and lowest in United Kingdom & Ireland (3.8%) (Supplementary Table 7). The preferred strategies to overcome obstacles were to integrate AF screening with other healthcare programs (24.9%) and to set up software systems with algorithms able to identify patients most suitable for AF screening (24.3%) (Table 2). These two options were preferred by all different regions with p-values of 0.054 and 0.076, respectively (Supplementary Table 8). FIGURE 2 Three out of five GPs (63.1%) indicated that opportunistic prolonged Availability of a standardized screening approach for different AF screening, in which at-risk patients wear an ECG patch for 2 weeks, conditions. would also be possible in their current practice, while 17.8% stated it would not be possible and 19.1% did not know (Supplementary Table 9). FIGURE 3 The perceived need for a standardized screening approach for different conditions, ranked on a scale from 0 to 100. Red dots: mean. Black bars: standard deviation. Frontiers in Cardiovascular Medicine 04 frontiersin.org Vermunicht et al. 10.3389/fcvm.2023.1112561 FIGURE 4 Regular health checks performed in patients ≥65 years coming for an outpatient visit. ECG, electrocardiogram; BMI, body mass index. TABLE 1 Main obstacles for implementing opportunistic single-lead ECG screening for atrial fibrillation in patients ≥65 years or patients at risk of atrial fibrillation, even if it would be reimbursed. Respondents (n=596) There are insufficient resources to perform AF screening in my practice (i.e., personnel, ECG devices) 18.5% I would need more education before undertaking AF screening 18.2% I am concerned about detecting false positives that could lead to anxiety/harm to patients 10.3% I am not confident about commencing treatment once AF has been diagnosed 7.0% None, I can easily start conducting AF screening 26.0% None, I have already implemented AF screening 6.2% Other (e.g., lack of evidence benefits AF screening, lack of time, administration issues) 13.8% The different responses were considered in relation to the total number of indicated reasons and presented as percentages. AF, atrial fibrillation; ECG, electrocardiogram. TABLE 2 Suggested strategies to overcome obstacles concerning opportunistic single-lead ECG screening for atrial fibrillation. Respondents (n=580) AF screening could be integrated with other programs (e.g., flu vaccination, cancer screening) 24.9% Integrated primary care software systems with algorithms to identify patients suitable for AF screening based on their age and/or medical history 24.3% Integrating advice pathways from experts to GPs on how to interpret ECGs and prescribe appropriately 15.5% Providing a structured way of analyzes of the tracings via a telehealth center 11.1% Provision of patient leaflets or other information to increase patient education 10.7% Additional settings (e.g., pharmacists or other healthcare professions) could be involved in screening 6.9% Other (e.g., distribution of validated single-lead devices, more evidence and education, decision support tools, better time management) 6.8% The different responses were considered in relation to the total number of indicated reasons and presented as percentages. AF, atrial fibrillation; ECG, electrocardiogram; GP, general practitioner. 4. Discussion study conducted in the framework of AFFECT-EU, in which healthcare professionals and regulators from 11 European countries In this quantitative survey, GPs shared their views on the confirmed that there are no systematic AF screening programs (6). implementation of opportunistic single-time point AF screening, Despite the ESC recommendation to conduct opportunistic AF focusing on the feasibility, requirements and barriers. screening by pulse taking or ECG rhythm strip in individuals The vast majority of GPs indicated that no AF screening program ≥65 years (5), the US Preventive Services Task Force argues against was available in their region. This is in line with the earlier qualitative implementation due to insufficient evidence on effectiveness, Frontiers in Cardiovascular Medicine 05 frontiersin.org Vermunicht et al. 10.3389/fcvm.2023.1112561 cost-effectiveness and potential harms (7). This lack of evidence was user-friendliness as they often require electrocardiographic or laboratory also indicated as a barrier by GPs in our current study. Questions parameters (18). Recently, Schnabel et al. developed a model based on remain about the advantages of AF detected by screening compared 13 predictors that can robustly identify patients at risk of AF using to routine care, in terms of stroke prevention and the benefits of machine learning techniques. This model could be implemented in anticoagulation (8). Data from recent studies, such as STROKESTOP automated screening tools to identify high-risk populations in primary and LOOP (9–11), were inconsistent, likely due to complex care (19). interactions between patient characteristics and screening strategies. This study reported that three out of five GPs have the capacity to However, in a current random effects model, AF screening was perform ECG patch screening in high-risk patients. Although prolonged associated with a reduction of stoke compared to no screening (12). patch use is often considered expensive and difficult (6), it seems a Several studies will report stoke outcome data in the near future, feasible approach for GPs. Moreover, previous studies like mSToPS, have which will provide guidance for decision making. already communicated that patch-based continuous ECG screening is In addition to general screening studies, research on the feasible in primary care and able to identify AF (20, 21). Also, the large- effectiveness of opportunistic screening specifically is also being scale GUARD-AF study (NCT04126486) is currently ongoing and will conducted. The AFFORD study in Denmark concluded that provide important information on the cost-effectiveness of patch-based opportunistic screening in primary care is feasible and results in the AF screening, informing future studies and guidelines (22). detection of new AF in 1% of patients (13). A similar study found a five-fold higher diagnostic yield of opportunistic screening compared to usual care (14). However, in the VITAL-AF study in 4.1. Regional differences the United States, screening for AF using a single-lead ECG at primary care visits did not affect new AF diagnoses among This study collected responses from 18 European countries, allowing individuals aged 65 years or older compared with usual care (1.72% us to examine regional differences. The most striking finding was that vs. 1.59%) (15). Similarly, a randomized controlled trial in the in United Kingdom & Ireland, some important steps appear to have Netherlands failed to show a significant difference in new AF been taken towards implementation of AF screening. For instance, diagnoses (1.62% in the screening group versus 1.53% in usual care) 63.6% of GPs already have a single-lead ECG device available; 36.4% (3). In several countries, usual care, irrespective of the methods used these devices during regular health checks in patients ≥65 years; used, already seems to be able to detect AF, making it more difficult the GPs felt most confident to rule out AF on a rhythm strip; and there to increase AF detection numbers by opportunistic screening (6). was the least need for additional education. In the United Kingdom, the Despite the lack of evidence, GPs appear to recognize the need for National Health Service (NHS), are promoting NHS Health Checks for AF screening programs almost as high as for various cancer screens, adults aged 40 to 74 in which GPs assess patients’ heart rhythms and likely due to the devastating impact that stroke as the result of determine whether AF is present if irregular. In addition, over 1,200 undetected AF might have. digital single-lead ECG devices have been delivered to GP practices in Interestingly, three in five GPs (59.3%) feel fairly or completely the United Kingdom to support opportunistic screening of undiagnosed confident to rule out AF on a 30 s single-lead ECG strip and 18% AF (23). would not need any additional assistance to perform it. It is The availability of a 12-lead ECG device in Southern and Eastern important to bear in mind the difference between ruling out AF and Europe was significantly lower than in the rest of Europe, possibly due diagnosing AF. A study in which 49 GPs reviewed ECG tracings from to the difference in total wealth and spending on health. In addition, 2,595 patients ≥65 years who were screened for AF as part of the Eastern Europe showed the greatest need for additional education and SAFE study, concluded that most GPs could not accurately detect AF attached great importance to screening not only for AF but for almost on either a 12-lead or a single-lead ECG. Therefore, the diagnosis of all proposed conditions. This suggests a certain gap between the AF AF should be made by appropriately trained people (16). and general health policies in Eastern Europe and United Kingdom & Nevertheless, these results are in contrast to those of Somerville et al. Ireland (24). However, it is important not to generalize these results who found that GPs could accurately detect AF on a 12-lead ECG for the whole of Eastern Europe, as Eastern Europe is mainly tracing (17). represented by Romania in this survey (87.4% of Eastern European Three out of ten GPs indicated that they could easily start or have respondents). To accommodate healthcare differences, e.g., differences already started opportunistic single-time point screening. Hence, the in numbers of GPs per head of population, the differing roles of GPs barriers perceived as most important (lack of education, insufficient staff within national healthcare systems and the time available to GPs per and ECG devices), seem to be surmountable. To facilitate the effective patient; and to set up national action plans and screening policies, implementation, GPs preferred two approaches of which the first was joint actions of ministries of health, governmental bodies, healthcare integration of AF screening with other healthcare programs. In the study professionals, clinical researchers and device industries will by Engler et al., regulators and healthcare professionals indicated that it be required. is not feasible to integrate AF screening with cancer screening programs due to the different target group and screening approach (6). Integration with flu vaccination does seem to be more appropriate. Secondly, GPs 4.2. Limitations would consider an integrated primary care software system with an algorithm able to identify patients suitable for AF screening based on The accessibility of GPs was considerably different in various their age and/or medical history. At this point in time, traditional risk European countries. In countries such as Romania, France and factor sets and scoring schemes such as the CHARGE-AF score are Belgium, GPs could be reached easily and efficiently by contacting rather limited in their predictive ability and have limited them personally via a mailing list of local GPs. In other countries, Frontiers in Cardiovascular Medicine 06 frontiersin.org Vermunicht et al. 10.3389/fcvm.2023.1112561 e.g., Germany and Italy, it proved more difficult to reach GPs, due Acknowledgments to the lack or minimal effect of such an up-to-date active mailing list. This may have led to some bias, and the situation in certain The authors thank the survey participants for their generous regions may be underrepresented in these survey results. As the contribution of time and effort. We also thank our contact persons for survey was distributed through various GP organizations and their essential support in making the distribution of the survey possible. personal GP networks, it is not possible to verify to how many people the survey was finally distributed to and no response rate can be determined. GPs with strong opinions on screening may be more Conflict of interest inclined to participate in the survey, therefore some selection bias is possible. BF has received grants to the institution for investigator-initiated studies from the BMS-Pfizer Alliance, personal fees and nonfinancial support from BMS-Pfizer Alliance and Pfizer, and loan devices 5. Conclusion from AliveCor. HH did receive personal lecture and consultancy fees from Abbott, GPs across Europe indicate a strong perceived need for a Biotronik, Daiichi-Sankyo, Pfizer-BMS, Medscape, and Springer standardized AF screening approach, which is currently absent in Healthcare Ltd. He received unconditional research grants through the most of Europe. In general, the perception of GPs concerning the University of Antwerp and/or the University of Hasselt from Abbott, implementation of opportunistic single time point AF screening with Bayer, Biotronik, Biosense-Webster, Boston-Scientific, Boehringer- a single lead ECG device was positive. Most GPs would already feel Ingelheim, Daicchi-Sankyo, Fibricheck/Qompium, Medtronic, and confident in ruling out AF based on a single-lead ECG strip. The Pfizer-BMS. identified obstacles, such as lack of education, evidence, and resources, HP received speaker fees from Bayer, Pfizer, Boehringer Ingelheim appear to be addressable. Finally, this study identified concrete and Daiichi-Sankyo. suggestions for implementing of AF screening in clinical practice, LN and CH hold an investigator initiated grant from Daiichi Sankyo namely integration with other healthcare programs and software (£75,000). systems with algorithms to identify patients most suitable MF received speaker fees from Pfizer Poland and Boehringer for screening. Ingelheim Poland. RS has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and Data availability statement innovation program under the grant agreement No 648131, from the European Union’s Horizon 2020 research and innovation program The raw data supporting the conclusions of this article will be made under the grant agreement No 847770 (AFFECT-EU) and German available by the authors, without undue reservation. Center for Cardiovascular Research (DZHK e.V.) (81Z1710103 and 81Z0710114); German Ministry of Research and Education (BMBF 01ZX1408A) and ERACoSysMed3 (031L0239). RS has received Ethics statement lecture fees and advisory board fees from BMS/Pfizer outside this work. This study, involving human participants, was reviewed and HW was employed by Pfizer Pharma GmbH, Berlin, Germany. approved by Ethik-Kommission der Ärztekammer Hamburg. The MH was employed by StopAfib.org, Dallas, TX, United States. participants provided their written informed consent to participate in The remaining authors declare that the research was conducted in this study. the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Author contributions Publisher’s note LD, DE, RS, HH, CH, LN, BF, HW, MH, JL, and KG contributed to conception of the study and to design and review of the survey. All claims expressed in this article are solely those of the MG, J-CD, CB, EP, GM, MF, MB, HP, CH, DE, RS, HH, LD, and PV authors and do not necessarily represent those of their affiliated contributed to the dissemination, promotion and/or translation of the organizations, or those of the publisher, the editors and the reviewers. survey. PV organized the database and performed the statistical analysis Any product that may be evaluated in this article, or claim that may be and wrote the first draft of the manuscript. All authors contributed to made by its manufacturer, is not guaranteed or endorsed by the the article and approved the submitted version. publisher. Funding Supplementary material The AFFECT-EU project has received funding from the European The Supplementary material for this article can be found online Research Council under the European Union’s Horizon 2020 research at: https://www.frontiersin.org/articles/10.3389/fcvm.2023.1112561/ and innovation program under the grant agreement no. 847770. full#supplementary-material Frontiers in Cardiovascular Medicine 07 frontiersin.org Vermunicht et al. 10.3389/fcvm.2023.1112561 References 1. Gruwez, H, Evens, S, Proesmans, T, Duncker, D, Linz, D, Heidbuchel, H, et al. 13. Hald, J, Poulsen, PB, Qvist, I, Holm, L, Wedell-Wedellsborg, D, Dybro, L, et al. Accuracy of physicians interpreting Photoplethysmography and electrocardiography Opportunistic screening for atrial fibrillation in a real-life setting in general practice in tracings to detect atrial fibrillation: INTERPRET-AF. Front Cardiovasc Med. 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