If your heart races or beats irregularly, get an electrocardiogram (ECG); if atrial fibrillation is found, ask a doctor to assess you for an anticoagulant to prevent stroke, and don't use aspirin instead

Cost

An ECG costs a few dozen CNY. Warfarin is very cheap, but you need regular blood draws to adjust the dose. The newer anticoagulants don't need frequent blood draws and cost more. The hard part is taking it every day even with no symptoms, and telling the doctor you are on an anticoagulant before a tooth extraction or surgery.

What you get

In atrial fibrillation the upper chambers of the heart quiver, blood pools in them, and it easily forms clots. A clot that travels to the blood vessels of the brain causes a stroke. The most common symptoms are a racing heart, tiring as soon as you are active, and discomfort in the chest, and about 25% of people say themselves that they have no symptoms. A single-lead ECG of 30 seconds or more, or an ordinary 12-lead ECG of 10 seconds or more, can confirm the diagnosis. A 2007 meta-analysis pooled 29 randomized trials with 28044 people. Compared with no treatment, dose-adjusted warfarin cut strokes by about 60% (64% fewer, plausible range 49% to 74%). Antiplatelet drugs like aspirin cut them by only about 20% (22% fewer, plausible range 6% to 35%). Compared head to head, warfarin cut strokes another 39% beyond antiplatelet drugs. The absolute increase in major bleeding outside the brain was no more than 0.3% a year. A Cochrane review looked only at 2313 people who had never had a stroke. Warfarin lowered death by about 30% (OR 0.69, 95% CI 0.50 to 0.94). 4 large trials with 71683 people in all compared the newer oral anticoagulants with warfarin. The new drugs cut stroke and embolism by a further 19% (RR 0.81) and death by 10% (RR 0.90). Bleeding inside the skull was 52% lower (RR 0.48), but bleeding in the stomach and intestines was 25% higher (RR 1.25). Aspirin cannot replace an anticoagulant. Among 5599 people who could not take warfarin, apixaban cut stroke and embolism by 55% compared with aspirin (HR 0.45). Major bleeding was 1.4% versus 1.2% a year, with no visible difference (HR 1.13, plausible range 0.74 to 1.75). Another trial enrolled only 973 people aged 75 and older. For fatal or disabling stroke, bleeding inside the skull and artery embolism taken together, warfarin was 52% lower than aspirin (RR 0.48). Bleeding outside the brain was 1.4% versus 1.6% a year. China's 2023 atrial fibrillation guideline scores risk with CHA2DS2-VASc-60. Heart failure, high blood pressure, diabetes, vascular disease, age 60 to 64 and being female each count 1 point, and age 65 or older and a previous stroke each count 2 points. For men with 2 points or more and women with 3 points or more, an oral anticoagulant is recommended. For men with 1 point and women with 2 points, it is considered after weighing bleeding risk against the person's own wishes. The guideline does not recommend antiplatelet drugs to prevent stroke caused by atrial fibrillation. The 2023 U.S. guideline states that whether to take one depends on stroke risk, not on whether the atrial fibrillation comes in episodes or is constant. It also states that a bleeding-risk score should not be used alone to decide against treatment, but to find bleeding factors that can be changed. A Chinese survey of people aged 45 and older in 2014 to 2016 found atrial fibrillation in 1.8%, about 7,900,000 (790万) people. Among those who had it, 78.3% in cities and only 35.3% in the countryside knew it. Only 6.0% of people with high-risk atrial fibrillation were taking an anticoagulant. In a national survey in 2020 to 2021, 43.8% of the atrial fibrillation found was newly discovered at that visit. Among people already diagnosed, 32.1% were taking an anticoagulant, and in the countryside only 19.8%

Notes

The dispute is on the screening side; there is no dispute about taking the medicine once atrial fibrillation is found. For people with no symptoms, the evidence is not enough to say whether to go looking for atrial fibrillation. The U.S. Preventive Services Task Force concluded in 2022 that the evidence is insufficient to judge the benefits and harms. Sweden invited people aged 75 to 76 to wear an ECG for two weeks, and about 7 years later death, stroke and bleeding combined were only 4% lower, barely enough to be a statistical difference. Denmark implanted a small long-term heart-rhythm recorder in people aged 70 to 90. Atrial fibrillation was found in 31.8% versus 12.2%, yet strokes did not fall by a visible amount. China's 2023 guideline says that for people 65 and older, checking the pulse or doing an ECG during a doctor visit can be considered. So if you have symptoms, go and get checked, and if you are 65 or older, ask the doctor to check your pulse during a visit; there is no need to buy a device just to screen. Once you are on an anticoagulant, don't add painkillers like ibuprofen on your own; see §34.3 (ask a doctor before taking ibuprofen while on an anticoagulant). The drug is long-term, so don't stop because you feel fine; see §16.1 (take your medicine as prescribed to the end). High blood pressure is also part of the score; see §1.7 (measure your blood pressure). People with atrial fibrillation don't all have to give up coffee; see §2.26 (three to four cups of coffee a day). If your mouth suddenly droops or one side goes weak, call 120 (China's ambulance number) right away whether or not you take the medicine; see §13.3 (mouth suddenly droops, one arm weak). The beneficiary is mainly you and the older people in your family.

Evidence grade

A : Specific numbers from meta-analyses, large cohorts or randomized trials; for law and policy, the statute or official text.

Sources

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2. Aguilar MI, Hart R. (2005). Oral anticoagulants for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks. Cochrane Database of Systematic Reviews, (3), CD001927. https://doi.org/10.1002/14651858.CD001927.pub2
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Translated from the Chinese original. Original book, section 1, tip 44. This section is about health and medicines. It is general information, not a substitute for a doctor’s diagnosis or prescription. Content may be out of date and rules differ by place. When you actually deal with an agency, a doctor or a court, follow what local officials, doctors and lawyers tell you. Disclaimer