Primary stroke prevention: a paradigm shift focusing on silent paroxysmal atrial fibrillation.

We review the prevalence, predictability, prognosis and preventability of atrial fibrillation and associated cardiogenic brain embolism, focusing on 'silent' sub-clinical atrial fibrillation (SCAF) which is very common in the elderly and associated with significantly increased risk of stroke and cardiovascular mortality. The current paradigm treats atrial fibrillation once discovered by its symptoms, complications (stroke) or by chance and screening recommendations are limited to opportunistic pulse palpation. We argue that the marked incidence of SCAF in patients over 65 justifies a much more active approach to identify patients at a particularly high-risk by routine evaluation of readily-available clinical, electrocardiographic, echocardiographic and laboratory markers. Elderly patients at high-risk need further monitoring by suitable devices (occasionally, long-term) and treatment with direct oral anti-coagulants once SCAF is revealed. This approach can already be adopted during clinical encounters at the general practitioner and consultant level, to decrease the substantial SCAF-associated morbidity and mortality.