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Targeted screening may be more efficient, however the appropriate location for screening programs has not been well defined. Our aim was to compare the cost\u2010effectiveness of unselected electrocardiographic (ECG) screening for atrial fibrillation (AF), and selective screening based on an abnormal echocardiogram.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Two strategies of portable ECG screening for AF were compared in the base case of a hypothetical asymptomatic 65\u2010year\u2010old man (CHA<jats:sub>2<\/jats:sub>DS<jats:sub>2<\/jats:sub>\u2010VASC\u00a0=\u00a03 based on hypertension and diabetes mellitus) with previous echocardiography but without a cause for AF (e.g. mitral valve disease, left ventricular (LV) dysfunction). With age\u2010based screening (AgeScreen; 3% AF detection rate) all patients underwent ECG. With imaging\u2010guided screening (ImagingScreen; 5% detection rate), only patients with left atrial (LA) volume \u226534 mL\/m<jats:sup>2<\/jats:sup> and LA reservoir strain &lt;34% or LV global longitudinal strain &gt; \u221218% underwent ECG screening. A Markov model was informed by published transition probabilities, costs and quality\u2010adjusted life years (QALY). Costs, effects and incremental cost\u2010effectiveness ratio were assessed for each screening strategy over a 20\u2010year period. The willingness\u2010to\u2010pay threshold was $53\u2009000\/QALY.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>ImagingScreen dominated AgeScreen, with a lower cost ($54\u2009823 vs $57842) and better outcome (11.56 vs 11.52 QALY over 20\u2009years). Monte Carlo simulation demonstrated that 61% of observations were more efficacious with ImagingScreen, with cost below willingness to pay. The main cost determinants were annual costs of stroke or heart failure and AF detection rates. ImagingScreen was more cost\u2010effective for AF detection rates up to 14%, and more cost\u2010effective across a range of annual stroke ($24\u2009000\u2013$102\u2009000) and heart failure ($4000\u2013$12\u2009000) costs.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>In patients with a previous echocardiogram, AF screening of those with baseline clinical and imaging risk parameters is more cost\u2010effective than age\u2010based screening.<\/jats:p><\/jats:sec>","DOI":"10.1111\/imj.15769","type":"journal-article","created":{"date-parts":[[2022,4,4]],"date-time":"2022-04-04T15:24:13Z","timestamp":1649085853000},"page":"760-772","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cost\u2010effectiveness of screening for paroxysmal atrial fibrillation in patients undergoing echocardiography"],"prefix":"10.1111","volume":"53","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6222-7003","authenticated-orcid":false,"given":"Satish","family":"Ramkumar","sequence":"first","affiliation":[{"name":"Department of Cardiac Imaging Baker Heart and Diabetes Institute  Melbourne Victoria Australia"},{"name":"School of Public Health and Preventative Medicine, Monash University  Melbourne Victoria Australia"},{"name":"Monash Heart, Monash Health  Melbourne Victoria Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hiroshi","family":"Kawakami","sequence":"additional","affiliation":[{"name":"Department of Cardiac Imaging Baker Heart and Diabetes Institute  Melbourne Victoria Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Edmond","family":"Wong","sequence":"additional","affiliation":[{"name":"Monash Heart, Monash Health  Melbourne Victoria Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mark","family":"Nolan","sequence":"additional","affiliation":[{"name":"Department of Cardiac Imaging Baker Heart and Diabetes Institute  Melbourne Victoria Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thomas H.","family":"Marwick","sequence":"additional","affiliation":[{"name":"Department of Cardiac Imaging Baker Heart and Diabetes Institute  Melbourne Victoria Australia"},{"name":"School of Public Health and Preventative Medicine, Monash University  Melbourne Victoria 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