Looking earlier for atrial fibrillation could prevent stroke for Indigenous Australians

A stroke prevention opportunity is being missed because the health system is looking too late.

Atrial fibrillation (AF) is a common heart rhythm condition. It can come and go, often causes no symptoms, and may not be noticed until a person has a stroke. Yet AF can be detected quickly, including through a pulse check or a 30-second single-lead ECG recording, and stroke risk can be substantially reduced when AF is diagnosed and managed in time.

For Indigenous Australians the timing of detection matters. In Australia, routine AF screening is currently recommended from age 65. That threshold may be reasonable for a population-wide approach, but it does not reflect the pattern of risk now documented for Indigenous Australians.

Our new systematic review, published in the Medical Journal of Australia, brings together evidence from 24 Australian studies. It found Indigenous Australians develop AF nearly 16 years earlier than other Australians. In some studies, almost half of AF cases among Indigenous Australians occurred before age 55. The review also found that AF-related stroke occurs at younger ages, outcomes are often more severe, and Indigenous Australians with AF are less likely to receive guideline-recommended therapies.

These findings point to a simple conclusion: if screening waits until 65, many people at risk will already have passed through the window where earlier diagnosis could have changed the course of their care.

AF is not only a rhythm problem

AF-related strokes are often more severe than other strokes, but they are also highly preventable. Appropriate treatment, including anticoagulant medicines when clinically indicated, can reduce stroke risk by around 60-70%.

First, AF has to be found. Second, it has to be acted on.

This is where the evidence is especially important. The review found Indigenous Australians with AF are more likely to have additional conditions that increase stroke risk, including diabetes, hypertension, kidney disease and rheumatic heart disease. It also found treatment gaps. Under-diagnosis and under-treatment compound each other. Detecting AF earlier will not prevent stroke unless it is followed by timely assessment, appropriate prescribing, support for adherence, and care that addresses the other cardiovascular risks a person may be living with.

What community-led screening has shown

This recommendation does not come from evidence alone. It also comes from more than a decade of research with Aboriginal communities and primary care services about how screening can work in practice.

Our earlier work began with local co-design: how to test, when to test, who should offer testing, and how to make the process culturally responsive and practical in busy primary care settings. Community members, clinicians and health service leaders shaped the approach. Katrina Ward, CEO of Brewarrina Aboriginal Medical Service and a descendant of the Ngiyampaa people of the Wongaibon nation, has led implementation in Brewarrina and has seen what early detection means in community-controlled care.

That work has shown AF screening using portable single-lead ECG devices is feasible and acceptable in Aboriginal Community Controlled Health Services and other primary care settings. Staff and patients found the devices easy to use. Opportunistic screening identified previously undiagnosed AF. When AF was detected, referral and treatment pathways could be activated.

Why 55 is the minimum starting point

Screening from 55 is not a special rule for its own sake. It is a risk-aligned response to the evidence. After reviewing the evidence, we convened an expert panel including cardiologists, epidemiologists, Aboriginal health leaders, and policy and practice experts. The panel unanimously recommended opportunistic AF screening from at least age 55 for Indigenous Australians, with earlier screening for people at higher stroke risk.

Technology is not the whole answer

Portable devices make AF easier to detect, but technology alone does not prevent stroke. Systems of care do.

When AF is detected, the next step should be a structured clinical review: confirm the diagnosis, assess stroke risk, consider anticoagulation where indicated, manage symptoms and rhythm, and address co-existing conditions that increase cardiovascular risk. Care pathways need to account for distance, cost, continuity of care, medication access and cultural safety. In practice, that means clear referral routes, timely review, culturally safe communication about diagnosis and treatment, support for shared decision making, and resourcing for Aboriginal Community Controlled Health Organisations and primary care teams that are already doing this work.

The clinical action is straightforward. The policy task is to make it routine.

National leadership is now needed to update AF screening recommendations in light of the evidence. 

Stroke is not inevitable

The case for earlier AF screening is not only about changing an age threshold. It is about matching prevention to the realities of risk.

Indigenous Australians develop AF earlier, experience stroke at younger ages, are more likely to live with co-existing cardiovascular risks, and are also less likely to receive the therapies that reduce avoidable harm.

Screening from age 55 will not close the cardiovascular gap by itself. But it is practical, evidence-based and immediately actionable. When AF is found earlier and treated well, disability can be prevented, independence preserved and lives saved.

** To support implementation, we have developed a free five-minute online training module to help primary care clinicians understand the evidence and apply earlier screening in practice. https://share.articulate.com/nXENXZjFO-LpTjb3L_KMD

Kylie Gwynne is an Associate Professor of Indigenous Studies at UNSW Sydney; Macquarie University;

Katrina Ward is a PhD Candidate in Nursing and Midwifery at RMIT University.

Vita Christie is a Senior Research Officer at the School of Population Health, UNSW Sydney.