Elderly Atrial Fibrillation Patients Research Articles

Oral anticoagulation in chronic kidney disease: A huge challenge

Editorial on Poli et al. Thromb Haemost 2012; 107: 1100-1106. The prevalence of chronic kidney disease (CKD) has doubled in the past 10 years related to the rise in obesity, diabetes and hypertension, becoming recognised as a silent epidemic (1). CKD is associated with an increased risk for cardiovascular morbidity and mortality, with the frequency of atrial fibrillation (AF) being especially high. Indeed, AF is common in patients with CKD at different stages of severity (1–4). Both conditions share several pathophysiological and clinical risk factors, such as hypertension, diabetes mellitus and coronary heart disease (5). Thus, the prevalence of AF increases with decreasing glomerular filtration rate (6), and conversely, CKD increases the risk of thromboembolism in AF independently of other risk factors (7). AF is the most common arrhythmia in clinical practice and associates a high morbidity and mortality due mainly to its fivefold increase in ischaemic stroke. The prevalence of AF increases with age, and age is also a risk factor for stroke, so the combination of age and AF means that stroke prevention in elderly AF patients is a huge challenge (8), added to the fact that CKD also increases with age. Oral anticoagulation reduces substantially the risk of stroke; however, elderly people are less likely to receive antithrombotic therapy, in spite of the net clinical benefit of oral anticoagulation in such patients (9, 10). Renal impairment is an established bleeding risk factor in patients taking oral anticoagulation. Several studies have reported the association between CKD and a significantly increased risk for bleeding in anticoagulated patients with AF or venous thromboembolism (11–14). Thus, CKD has been included in the HAS-BLED bleeding score (15) which has been proposed in current AF clinical guidelines (16, 17), or other risk scores like the HEMORRHA2GES (18), or more recently, the ATRIA based bleeding risk score (19). In a similar way, the RIETE investigators have derived and validated a score to predict the risk of major bleeding for venous thromboembolism which also includes renal impairment (20). In the June 2012 issue of Thrombosis and Haemostasis, the investigators of the EPICA study, reported that CKD is an independent risk factor for bleeding and that a wide proportion of aged patients taking oral anticoagulation had severe or moderate CKD independently of the method used for measuring glomerular filtration rate (21). Whilst the abbreviated MDRD (Modification of Diet in Renal Disease) formula is more accurate in estimating the glomerular filtration rate in elderly patients (22), it has recently been proposed that the CockroftGault formula is the better method to evaluate renal function in heart failure patients (where it was predictive of mortality), although the latter patients were about 10 years younger (23). In the study by Poli et al., the Cockroft-Gault formula seemed to overestimate the incidence of severe CKD, as previously reported – also, independent of the formula used to calculate, severe CKD patients (creatinine clearance less than 30 ml/ minute) was associated with an independent increased risk of bleeding (21). There is much renewed interest regarding to the evaluation of renal function in AF patients, as the new oral anticoagulants are contraindicated in patients with severe renal impairment (24), which could have implications for thromboprophylaxis. Indeed, the oral direct thrombin inhibitor dabigatran is highly excreted by the kidneys so there could be an increased risk of bleeding secondary to the accumulation of the drug (25). Indeed, patients with severe renal dysfunction were excluded from the recent clinical trials with new oral anticoagulants (26). Also, the management of warfarin therapy in severe CKD patients is difficult as they require lower warfarin dosages, spend less time on therapeutic range and are at risk of overanticoagulation (27). Nonetheless, stroke risk is closely related to bleeding risk in AF patients (28), as many risk factors for stroke are also associated with a higher risk for anticoagulation associated haemorrhage (17). CKD does not only coexist with advancing age, but also with hypertension, diabetes, heart failure and vascular disease, which are included within current stroke risk stratification schemes such as the CHA2DS2-VASc score (29). Severe renal dysfunction is not included in neither of the two stroke risk stratification scores, but it has already been informally proposed in 2010 that it could be included in CHA2DS2-VASc score, with the little “c” letter indicating “chronic severe renal impairment” pending validation studies (3). Renal impairment is at least included in the HAS-BLED score, which also does have some modest predictive value for cardiovascular events and mortality, but less so compared to its predictiveness for major bleeding (where as a bleeding score, HAS-BLED performs as good as a multivariate analysis) (12). Several studies agree that stroke risk stratification in severe CKD patients should be individualised which is essential to guide the selection of the most appropriate thromboprophylactic measures (30, 3 © Schattauer 2012

Abstract 17371: Benefits and Risks of Catheter Ablation of Atrial Fibrillation in Elderly Patients (75 Years or Older)

Published reports of atrial fibrillation (AF) treatment by catheter ablation (CA) included typically relatively young healthy individuals, but long-term outcomes of CA in elderly patients (PTs) remain unclear. We thus carried out the following study aiming to determine: 1) Safety and efficacy of CA in elderly PTs in maintaining sinus rhythm; 2) Risks of discontinuation of anti-coagulation in patients who remained in sinus rhythm (SR) after the ablation. Methods: We evaluated 302 elderly AF PTs (> 75 years old); 246 PTs (mean age = 80) underwent CA guided by complex fractionated atrial electrogram (CFAE); 85 were paroxysmal AF, 46 persistent AF and 115 long-lasting AF. The remaining 56 patients (mean age = 79) declined the procedure. The clinical end points were SR, stroke, death and major bleeding. Warfarin was discontinued if sinus rhythm was maintained or AF burden < 5% with no AF episodes was > 12 hours. Results: After a mean follow-up of 3 + 6 years including multiple ablations, 196 Patients (79 %) remained in SR. The annual death rate was 4% vs. 10% in PTs who stayed in SR vs. those remained in AF after ablations respectively (p < 0.001); interestingly, the annual death rate was also at 11% in patients who declined ablation. We were able to discontinue warfarin in 164 patients (70%) who had a stroke rate only 1.08 per 100 person -year compared to 2.62 per 100 person-year in patients who continued to have AF and stayed on coumadin (p <0.01). Patients with CHADS score > 2, who stayed in SR and stopped warfarin, had a stroke rate of 2 per 100 person-year compared to 0.98 for those with CHADS score 1. Major complications were groin bleeding (n= 9 [4%]), 2 patients had stroke (1 intracranial hemorrhage leading to death at home) and 2 patients had hemopericardium. Conclusions: Our data suggest that elderly PTs with AF benefit from AF substrate ablation which is safe and effective in maintain SR. Warfarin could be safely discontinued after SR is maintained post ablation. Our data suggest that SR after CA is associated with lower mortality and stroke risks.

Stroke prevention in elderly patients with atrial fibrillation: challenges for anticoagulation

Elderly patients with atrial fibrillation (AF), who constitute almost half of all AF patients, are at increased risk of stroke. Anticoagulant therapies, especially vitamin K antagonists (VKA), reduce the risk of stroke in all patients including the elderly but are frequently under-used in older patients. Failure to initiate VKA in elderly AF patients is related to a number of factors, including the limitations of current therapies and the increased risk for major haemorrhage associated with advanced age and anticoagulation therapy. Of particular concern is the risk of intracranial haemorrhages (ICH), which is associated with high rates of mortality and morbidity. Novel oral anticoagulant agents that are easier to use and might offer similar or better levels of stroke prevention with a similar or reduced risk of bleeding should increase the use of antithrombotic therapy in the management of elderly AF patients. Amongst these new agents, the recently approved direct thrombin inhibitor dabigatran provides effective stroke prevention with a significant reduction of ICH, and enables clinicians to tailor the dose according to age and haemorrhagic risk.

Non-Surgical Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation

Non-Surgical Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation. The most feared complication associated with atrial fibrillation (AF) is stroke, the risk of which increases with advanced age. Because of its complex anatomy and diminished blood flow during AF, the left atrial appendage (LAA) has been a common site of left atrial thrombi and presumed source of thromboembolism. Systemic anticoagulation to treat what may be largely a localized phenomenon is associated with significant complications. Newer anticoagulation agents hold great promise in facilitating dosing and eliminating drug and food interactions, but do not eliminate bleeding risk. These challenges have led to interest in mechanical exclusion of the LAA as a means of preventing thromboembolism in AF. Although surgery permits greater visualization and management of complications, the potential morbidity has limited adoption in often-frail elderly patients. In this paper, we review the current state of percutaneous left atrial exclusion for stroke prevention in AF, and the strengths and limitations of each of these strategies. The nonsurgical approaches to excluding the LAA from the central circulation can be divided into 3 broad categories: transseptally placed devices, percutaneous epicardial approach, and hybrid approaches. The availability of several approaches will allow physician selection of the optimal approach for a given patient based on clinical, physiological, and anatomical considerations. LAA exclusion stands to become an increasingly attractive option for patients with nonvalvular AF because it can be offered to elderly AF patients, and eliminates the long-term cumulative bleeding risks and adherence challenge of anticoagulants.

Treatment of atrial fibrillation in the elderly: time for a change?

Treatment of atrial fibrillation in the elderly: time for a change?

Cardiac Arrhythmias in Obstructive Sleep Apnea (from the Akershus Sleep Apnea Project)

Increased prevalence of cardiac arrhythmias has been reported in patients with severe obstructive sleep apnea (OSA), but this may not be generalizable to patients from the general population with a milder form of the condition. The aim of this study was to assess the association between cardiac arrhythmias and OSA of mainly mild and moderate severity. In total, 486 subjects (mean age 49 years, 55% men) recruited from a population-based study in Norway underwent polysomnography for OSA assessment and Holter recordings for arrhythmia assessment. Of these, 271 patients were diagnosed with OSA (apnea-hypopnea index [AHI] ≥5, median AHI 16.8, quartiles 1 to 3 8.9 to 32.6). Mean nadir oxygen saturations were 82% and 89% in patients with and without OSA, respectively. Ventricular premature complexes (≥5/hour) were more prevalent in subjects with OSA compared to subjects without OSA (median AHI 1.4, quartiles 1 to 3 0.5 to 3.0) during the night (12.2% vs 4.7%, p = 0.005) and day (14% vs 5.1%, p = 0.002). In multivariate analysis after adjusting for relevant confounders, AHI was independently associated with an increased prevalence of ventricular premature complexes at night (odds ratio per 1-U increase of log-transformed AHI 1.5, 95% confidence interval 1.1 to 2.0, p = 0.008) and during the day (odds ratio 1.37, 95% confidence interval 1.0 to 1.8, p = 0.035). In conclusion, the prevalence of ventricular premature complexes is increased in middle-aged patients with mainly mild or moderate OSA, suggesting an association between OSA and ventricular arrhythmias even in mild OSA.

Atrial fibrillation in elderly patients with heart failure: convergence of two cardiovascular epidemics in the 21st Century

Atrial fibrillation and heart failure have been called the twin cardiovascular epidemics of the 21st Century. The prevalence of both conditions is increasing in the elderly and often the two conditions coexist in the same patients, leading to worse outcomes. Current data show that rate control and rhythm control are both reasonable strategies for the treatment of atrial fibrillation in heart failure patients. Emerging data suggest the beneficial effects of novel therapeutic approaches such as cardiac resynchronization therapy, and pulmonary vein isolation on left ventricular remodeling and functional outcomes. Anticoagulation remains a mainstay of therapy for stroke prevention in this high-risk population.

Incidence Rate and Risk Factors of Bleeding Associated with Warfarin Therapy in Elderly Atrial Fibrillation Patients

Incidence Rate and Risk Factors of Bleeding Associated with Warfarin Therapy in Elderly Atrial Fibrillation Patients

One‐year cholesterol lowering treatment reduces medial temporal lobe atrophy and memory decline in stroke‐free elderly with atrial fibrillation: evidence from a parallel group randomized trial

In elderly patients with atrial fibrillation (AF), medial temporal lobe (MTL) atrophy and white matter lesions (WML) may account for the cognitive decline. Though a combination therapy of statins with cholesterol lowering agents like ezetimibe may be beneficial in patients with AF, its effects on MTL structure and WML remains unknown. A parallel group double-blinded randomized trial was performed during 1 year whereby elderly stroke-free AF patients either received placebo or atorvastatin and ezetimibe on top oral anticoagulation therapy. Neuropsychological performance and inflammatory markers in the blood were assessed at baseline and 1 year later together with amygdala and hippocampal volume as well as WML. Sixty-three patients were assessed for eligibility, but 29 patients had to be excluded so that 34 patients were randomized to both groups. In the treatment group, the systemic level of inflammation was significantly decreased after 1 year and an improvement in cognitive speed as well as short- and long-term memory was observed. While there was no significant difference in MTL volume at baseline, the placebo group exhibited more atrophy for right amygdala and left hippocampus at follow-up. Finally, descriptive data showed a slight decline of WML volume in the treatment group. In spite of limitations due to small sample size, our data suggest that intensive cholesterol lowering therapy in AF patients may slow cognitive decline and atrophy of the MTL. Though these results have to be replicated in a larger sample, they offer potential for future interventions.

Long term treatment of atrial fibrillation in elderly patients: A decision analysis

BackgroundAtrial fibrillation (AF) is more frequent with age but it is not clear whether, and how, older age should influence therapeutic choice. MethodsWe developed a Markov decision analytic model simulating the long term effectiveness of 4 therapeutic strategies (rate control (RateC) or rhythm control (RhythmC) using amiodarone, each combined with aspirin or warfarin) in two hypothetical cohorts of patients with persistent AF, 60 and 80years old at baseline. Two different base risks of stroke, low and moderate/high, were analysed. Outcomes studied were: predicted mortality, quality-adjusted years (QALYs), stroke, and disability. Time horizon was 10years. ResultsAll results applied similarly to patients 60 and 80years old at baseline. RateC+warfarin obtained in all cases the lowest predicted mortality (0.5% to 3.9% absolute reduction). RateC+warfarin also gained the more cumulated QALYs in patients at moderate/high risk of stroke, but RateC+aspirin obtained better results in QALYs in patients at low risk of stroke. Differences between strategies in terms of QALYs were limited (0.07 to 0.25 QALY of difference).Sensitivity analysis identified four variables, the same in younger and in older patients, that could change which strategy was optimal: impact on quality of life provoked by AF and by warfarin treatment, baseline risk of stroke and risk of major bleeding on warfarin. ConclusionsNo important difference in the decision making between patients 60 and 80years old was found. Several individual variables influenced the optimal choice of long term treatment of AF, but not age by itself.

Use of digoxin for heart failure and atrial fibrillation in elderly patients

Background: Digoxin has been reported to improve symptoms and reduce hospitalization in patients with heart failure as well as to control rapid ventricular rate in patients with atrial fibrillation. Both of these are high-prevalence diseases in the elderly, and yet studies have indicated that digoxin may not be used appropriately in this population. Clinical trials evaluating digoxin use specifically in the elderly are scarce. Objective: This article discusses the evidence on the therapeutic use of digoxin in the elderly and the changes in the pharmacokinetics of digoxin with aging to provide recommendations about the appropriate use of this drug in this population. Methods: Peer-reviewed clinical trials, review articles, and relevant treatment guidelines limited to those evaluating patients aged >65 years were identified from MEDLINE and the Current Contents database (both from 1966 to May 1, 2010) using the search terms digoxin, pharmacokinetics, heart failure, and atrial fibrillation. Citations from available articles were also reviewed for additional references. Results: One pharmacokinetic study, 8 clinical trials, and 2 guidelines were identified as relevant to digoxin use specifically in the elderly. In an elderly population (aged ≥65 years; n = 7) compared with a younger population (aged <65 years; n = 6), the elderly had a significant increase in digoxin t 1/2 (mean [SD]: oral dosing, 69.6 [13.1] vs 36.8 [4.5] hours; N dosing, 68.8 [12.3] vs 38.2 [3.5] hours; both, P < 0.05) and a decrease in total-body clearance (0.8 [0.2] vs 1.7 [0.2] mL/min/kg; P < 0.05). The use of digoxin in heart failure has been found to reduce the risk of hospitalization (risk ratio = 0.72; 95% CI, 0.66-0.79; P < 0.001). This beneficial effect of digoxin was found to be not significantly different across age groups in those aged >18 years. In terms of atrial fibrillation, the ability of digoxin to control the ventricular rate is believed to be caused by its vagotonic effect on the atrioventricular node. Therefore, digoxin is recommended for ventricular rate control only in patients with heart failure or sedentary lifestyle (ie, low sympathetic tone), or in those who cannot tolerate other rate-control agents. Because the prevalence of heart failure is high among the elderly (15.2 per 1000 population at age 65–74 years, 31.7 per 1000 population at age 75–84 years, and 65.2 per 1000 population at age ≥85 years), many of whom have a relatively sedentary lifestyle, digoxin may be an appropriate agent for ventricular rate control in the elderly. Conclusions: The elderly population appears to gain comparable benefits as does a younger population from the use of digoxin for heart failure management in terms of symptom improvement and reduction of hospitalization. In atrial fibrillation, digoxin does not control the ventricular rate as efficaciously during exercise and in high adrenergic states as do R-blockers and calcium channel blockers. The elderly have reduced elimination of digoxin, so if digoxin is to be used, the dosing strategy must be conservative and therapeutic monitoring is needed. Further clinical studies are needed to confirm the pharmacokinetic parameters of digoxin in elderly patients with heart failure and/or atrial fibrillation.

Low serum thyrotropin concentrations as a risk factor for atrial fibrillation in elderly patients

Results Serum TSH values was <0.5 fiUI/ml in 24 (32%, Group A), between 0.5 and 1 fiUI/ml in 22 (29.3%, Group B) and above 1 fiUI/ml in 29 (38.7%, Group C) patients. No significant difference was observed among the 3 groups for echocardiographic parameters. Holter registration showed : Heart Rate [HR (24 hours)] of 67.7 + 10.8 b/m in the group A, 71.8 + 8.9 b/m in the group B and 70.5 + 18 b/m in the group C; HR (Max) of 134.6 + 35.2 b/m in the group A, 124 + 22.8 b/m in the group B and 119.6 + 40.8 b/m in the group C; HR (Min) of 43.8 + 8.3 in the group A, 43.7 + 11 b/m in the group B and 45.8 + 14.6 b/m in the group C; Diurnal HR of 71 + 10 b/m in the group A, 75.3 + 8.9 b/m in the group B and 69.7 + 12 in the group C and Nocturnal HR of 68 + 11 b/m in the group A, 65.6 + 8.4 b/m in group B and 61.4 + 9.5 b/m in the group C. Persistent AF was observed in 17/24 (70.8%) patients in the group A, in 8/22 (36.4%) patients in the group B and in 9/29 (31.0%) patients in the group C. Conclusions In conclusion, the 24 h, the Maximal and the Minimal HR did not significantly differ among the 3 groups; the circadian HR variation was lost in group A patients, while it was present in the other groups; the frequency of persistent AF was significantly increased in group with serum TSH values <0.5 μU/ml.

Anticoagulation intensity for elderly atrial fibrillation patients: Should we use a conventional INR target (2.0 to 3.0) or a lower range?

Anticoagulation intensity for elderly atrial fibrillation patients: Should we use a conventional INR target (2.0 to 3.0) or a lower range? -

Prediction of Transition to Chronic Atrial Fibrillation in Elderly Patients with Nonvalvular Paroxysmal Atrial Fibrillation by Transthoracic Doppler Echocardiography

It is well known that paroxysmal atrial fibrillation (PAF) often precedes the development of chronic atrial fibrillation (CAF). The purpose of this study was to determine prospectively whether transthoracic echocardiography is useful for the prediction of the transition to CAF in elderly patients with nonvalvular PAF. Forty-two consecutive elderly patients (> or =65 years) with nonvalvular PAF were prospectively evaluated after undergoing transthoracic echocardiography. The study endpoint was the transition to CAF (AF; > or = 6 mo). During a follow-up period of 32 +/- 24 mo, 12 patients developed CAF. Patients with CAF had a significantly lower peak A velocity (A) and a higher E/A ratio of the transmitral inflow (TMF) such as a pseudonormalization pattern, and a lower peak atrial reversal wave velocity, higher peak diastolic wave velocity (D), and lower peak systolic/diastolic wave velocity ratio (S/D ratio) of the pulmonary venous flow (PVF). Kaplan-Meier analysis revealed that the transition to CAF was observed more often when A was < or = 70 cm/sec and E/A ratio was > or = 1.07 of TMF, and D was > or = 44 cm/sec and the S/D ratio was < or = 1.34 of PVF. All patients developed CAF when the E/A ratio was > or = 1.15 or the S/D ratio was < or = 0.75. This prospective study suggests that elderly patients at high risk for transition to CAF have a pseudonormalization pattern of TMF and a diastolic dominant pattern of PVF, and that transthoracic Doppler estimation of TMF and PVF may be useful in identifying elderly patients at high risk for the transition from nonvalvular PAF to CAF.

Bleeding Risk During Oral Anticoagulation in Atrial Fibrillation Patients Older Than 80 Years

We sought to evaluate the rate of bleeding in relation to age (<80 and > or =80 years), the quality of anticoagulation (expressed as time spent in international normalized ratio therapeutic range), and factors associated with bleeding events. Stroke prevention in patients with atrial fibrillation (AF) is an increasingly crucial public health target, particularly in patients ages > or =80 years. We conducted a prospective observational study on 783 patients with AF on oral anticoagulant treatment (OAT). Patients spent a median 14%, 71%, and 15% of time below, within, and above the intended therapeutic range, respectively. No difference in OAT quality was found between patients age <80 and > or =80 years. During follow-up, 94 patients experienced bleeding complications (rate 3.7 x 100 patient/years), 37 major (rate 1.4 x 100 patient/years), and 57 minor (rate 2.2 x 100 patient/years). Different rates of major hemorrhage were observed between patients age <80 and > or =80 years (0.9 vs. 1.9 x 100 patient/years; p = 0.004). Bleeding risk also was greater in patients with a history of previous cerebral ischemic event (odds ratio [OR]: 2.5; 95% confidence interval: 1.3 to 4.8; p = 0.007). A Cox regression analysis confirmed age > or =80 years associated with bleeding risk (OR: 2.0). These results indicate that the rate of major bleeding complications may be kept acceptably low also in very elderly AF patients on OAT, provided a careful management of anticoagulation is obtained.

Safety of the Combination of Intensive Cholesterol-Lowering Therapy with Oral Anticoagulation Medication in Elderly Patients with Atrial Fibrillation

The incidence of atrial fibrillation (AF) is very high in the elderly, and often oral anticoagulation (OAC) is indicated to prevent thromboembolism. The aim of this study was to evaluate the safety of combining intensive cholesterol-lowering therapy with OAC in elderly patients with AF. In a randomized, double-blind trial, 34 patients received OAC plus atorvastatin 40 mg/day and ezetimibe 10 mg/day versus placebo over 1 year. Dose adjustments of OAC served as an indicator of an interaction between HMG-CoA reductase inhibitors (statins) and OAC. Safety was evaluated by the occurrence of bleeding and a rise in AST, ALT and creatine phosphokinase. Compared with a 6-month pre-intervention period, the mean daily dose +/- standard error of OAC was 4.4 +/- 1.5% lower in the treatment group (p = 0.003) and virtually the same in the placebo group (change from baseline: -0.1 +/- 1.3%, p = 0.96). The mean daily dose of OAC stabilized after 3 months. In the 6-month post-intervention period, OAC dosing showed no statistically significant change from baseline: -1.9 +/- 1.9% in the placebo arm and -2.6 +/- 2.1% in the intervention arm. We conclude that in elderly AF patients treated with OAC, intensive cholesterol-lowering therapy (atorvastatin 40 mg/day and ezetimibe 10 mg/day) is well tolerated. No increased risk in bleeding was found.

P-20 Impact of Atrial Fibrillation in Elderly Patients with Hypertrophic Cardiomyopathy: Results from Kochi Cardiomyopathy Network

P-20 Impact of Atrial Fibrillation in Elderly Patients with Hypertrophic Cardiomyopathy: Results from Kochi Cardiomyopathy Network

Does the Combination of Warfarin and Aspirin Have a Place in Secondary Stroke Prevention?

The combined use of warfarin plus aspirin for secondary stroke prevention occurs primarily in patients with atrial fibrillation (AF) who have concomitant coronary artery disease (CAD). This drug combination is also used in patients with mechanical heart valves or occasionally in stroke/TIA patients who are deemed to be at high-risk for recurrent events. It is estimated that approximately 20% of patients on warfarin also receive aspirin and aside from patients with mechanical heart valves the use of this combination is tenuous.1,2 The most common clinical scenario for using warfarin plus aspirin is for primary or secondary stroke prevention in AF patients who also have CAD. The rationale for using this combination typically is the widespread belief that the use of warfarin, although clearly of benefit for stroke risk reduction, should be supplemented with aspirin for reducing the risk of coronary ischemic events. The basis for this assumption is unclear, and the combined use of warfarin plus aspirin substantially increases the risk of major bleeding side effects, including intracerebral hemorrhage (ICH).2 The efficacy of aspirin for reducing ischemic …

Medical treatment of patients with atrial fibrillation aged over 80 years in daily clinical practice: Influence of age and CHADS 2 score

The purpose of the present study was to evaluate clinical data and medical treatment of very elderly patients with atrial fibrillation (AF) who are under-represented in the majority of AF studies. In this retrospective study, patients over 80 years with AF admitted to the cardiology ward during a 1-year period were investigated with respect to the type of AF, clinical characteristics, and rate or rhythm control strategy. In addition, the influence of age and CHADS 2 score on antithrombotic therapy was examined. A total of 169 consecutive patients (mean ± S.D. age: 84.7 ± 4.0 years) were included in this study. Rate control medication was administered in 79% of the patients at discharge. Oral anticoagulation (OAC) was prescribed in only 27.5% of the patients with a CHADS 2 score of ≥2 for reasons of poor compliance or unfavorable clinical conditions. Moreover, patients older than 85 years received OAC less frequently than those aged between 80 and 84 years (7% vs. 36%, p < 0.001). Our results indicate a real need for educational programs aimed at instructing all staff involved with this group of patients, so that the necessary pre-conditions for a maximum OAC therapy can be achieved in these very elderly AF patients.

Pharmacotherapy for rhythm management in elderly patients with atrial fibrillation

This review examines pharmacotherapy of rhythm management for atrial fibrillation (AF) in the elderly. There is little research specifically focused on this topic in the elderly but five of the seven randomized controlled trials comparing pharmacologic rate control to pharmacologic rhythm control enrolled patients who can be considered "elderly". Collectively, these studies showed that the rate control approach was favored for the outcomes of mortality, hospitalization and cost. With respect to stroke and systemic thromboembolism, no clear advantage accrues to either approach and the major therapeutic intervention for stroke prevention is anticoagulation. Rhythm control may be better for relief of symptoms in those who are highly symptomatic but symptoms are usually less problematic in the elderly. Little comparative information is available about use of specific drugs in the elderly but beta blockers are probably the preferred initial therapy for rate control when possible. Although amiodarone is the most effective rhythm control agent, its adverse effect profile suggests it should be reserved for use when other antiarrhythmic drugs fail or are contraindicated. To date, "upstream" or preventive therapies have not been specifically evaluated in the elderly but nebivolol (a beta blocker) does not prevent emergence of AF in elderly patients with heart failure, although it does provide the other salutary benefits of beta blocker therapy seen in younger heart failure patients.