Atrial Fibrillation In Elderly Research Articles

Left atrial strain after paroxysmal atrial fibrillation linac-based cardiac radioablation in elderly population.

Catheter ablation of atrial fibrillation (AF) may increase the risk of complication in aged patients. Stereotactic arrhythmia radioablation (STAR) is a non-invasive therapeutic alternative for cardiac arrhythmia. This sub-study evaluated left atrial strain (LAS) in elderly AF patients underwent STAR. Symptomatic paroxysmal AF patients aged > 70 years, with antiarrhythmic drugs failure or intolerance, enrolled in a phase II trial that have demonstrated the feasibility of LINAC-based STAR (total dose of 25Gy single fraction delivered in 3min), performed a 15-day electrocardiogram Holter monitoring to detect AF episodes (≥ 30s) and an echocardiographic LAS evaluation before and after STAR (at 1-, 3-, 6- and 12-month). Out 18 patients underwent STAR in the trial, 16 (7 males, 78 ± 5 years) completed the follow-up for LAS study. No baseline difference in echocardiographic and LAS parameters was observed between the 9 patients with AF recurrence during follow-up and those who maintained sinus rhythm. At 6- and 12-month after STAR, LAS reservoir was lower in patients with AF episodes than those without (respectively, p = 0.039 and p = 0.001). Values of left atrial area and volume as well as LAS conduit and contractile phase were not statistically significant different by patient's outcome across evaluations. Although no baseline LAS parameter before STAR seems predict AF recurrence after treatment in elderly patients, lower values of reservoir phase were observed during follow-up in those experiencing AF episodes. More research is needed to better assess the value of LAS monitoring in paroxysmal AF patients underwent Stereotactic cardiac radioablation.

Association of sex with heart rate variability in atrial fibrillation patients

Abstract Background Sex-specific differences in cardiac autonomic tone have not been thoroughly investigated in patients with atrial fibrillation (AF) but may play a relevant role. Purpose We aimed to investigate cardiac autonomic function of female compared to male AF patients by means of short-term heart rate variability (HRV) analysis. Methods In this cross-sectional analysis, we enrolled 1150 patients from the Swiss-AF cohort study with 5-minute resting ECG recordings in sinus rhythm. We calculated the following HRV parameters: HRV triangular index (HRVI), standard deviation of NN intervals (SDNN), root mean square of successive differences, mean heart rate, power in the high frequency and low frequency range. We fitted linear regression models to analyze the association between gender and HRV variables adjusted for age, intake of betablockers, hypertension, diabetes and heart failure. Results 361 patients (29%) were female (mean age 72.9±7.8 years), 789 (68.6%) were male (mean age 69.8±8.5 years). In the multivariable adjusted models, female sex was associated with significantly lower values of HRVI (β = -0.74; 95% CI -1.44- -0 04, p=0.039) and SDNN (β = 8.95; 95% CI 0.162-17.7, p=0.046). This association persisted in all three age tertiles (<68 years, 68-75 years and ≥ 75 years of age). Conclusions In an elderly AF cohort, female sex is associated with reduced global autonomic activity. Whether this is associated with an adverse prognosis has to be investigated.

Comparative Bleeding Risk of Brand Vs Generic Rivaroxaban in Elderly Inpatients with Atrial Fibrillation.

Atrial fibrillation (AF) is the most common abnormal heart rhythm in elderly patients. Rivaroxaban has been widely used for stroke prevention. The anticoagulant response to rivaroxaban increases with age, which may make elderly patients susceptible to adverse outcomes resulting from small differences in bioavailability between generic and brand products. We designed a cohort study of ≥65-year-old inpatients with AF. Sociodemographic and laboratory measures of qualified patients who received brand or generic rivaroxaban for at least 72 hours at the study hospital from January 2021 to June 2023 were collected retrospectively. The primary outcome was the incidence of bleeding. A total of 1008 qualifying patients were included for analysis, with 626 (62.1%) receiving brand rivaroxaban and 382 (37.9%) receiving generic rivaroxaban. After propensity score matching and weighting to account for confounders, the odds ratios comparing brand vs generic rivaroxaban (95% confidence intervals) for the bleeding was 1.15 (0.72-1.82). Results from subgroup analyses of patients with age ≥85, HAS-BLED score ≥3, containment of antiplatelet drugs, and female patients were consistent with the primary analysis. It provides evidence regarding the clinical safety outcome of generic rivaroxaban in the elderly AF population that may be particularly susceptible to adverse outcomes resulting from small allowable differences in pharmacokinetics.

Gastrointestinal bleeding in elderly patients with atrial fibrillation: prespecified All Nippon Atrial Fibrillation in the Elderly (ANAFIE) Registry subgroup analysis

Gastrointestinal (GI) bleeding control is critical in elderly patients with atrial fibrillation (AF) receiving oral anticoagulants (OAC). This subgroup analysis aimed to clarify the actual state and significance of GI bleeding in elderly non-valvular AF (NVAF) patients. We evaluated the incidence and risk factors of GI bleeding during the 2-year follow-up and examined the GI bleeding impact on mortality. Of the 32,275 patients in the ANAFIE Registry, 1139 patients (3.5%) experienced GI bleeding (incidence rate, 1.92 events per 100 person-years; mean follow-up, 1.88 years); 339 upper and 760 lower GI bleeding events occurred. GI bleeding risk factors included age ≥ 85 years, body mass index ≥ 25.0 kg/m2, prior major bleeding, hyperuricaemia, heart failure, P-glycoprotein inhibitor use, GI disease, and polypharmacy (≥ 5 drugs). No significant differences in GI bleeding risk were found between direct OAC (DOAC) vs warfarin users (adjusted hazard ratios [95% confidence interval], 1.01 [0.88–1.15]). The 1-year post-GI bleeding mortality rate was numerically higher in patients with upper (19.6%) than lower GI bleeding (8.9%). In elderly Japanese NVAF patients, this large-scale study found no significant difference in GI bleeding risk between DOAC vs. warfarin users or 1-year mortality after upper or lower GI bleeding.

Clinical outcomes and anticoagulation therapy in elderly non-valvular atrial fibrillation and heart failure patients.

Atrial fibrillation (AF) and heart failure (HF) often coexist. Older age is strongly associated with stroke, HF, and mortality. The association between coexistence of HF and a risk of clinical outcomes and the effectiveness of anticoagulation therapy including direct oral anticoagulants (DOACs) in elderly patients with AF and HF have not been investigated. We aimed to evaluate 2years of outcomes and to elucidate the efficacy of DOACs or warfarin in elderly AF patients in the All Nippon AF In the Elderly (ANAFIE) Registry with and without a history of HF. The ANAFIE Registry is a multicentre, prospective observational study following elderly non-valvular AF patients aged ≥75years for 2years. Hazard ratios (HRs) were calculated based on the presence or absence of an HF diagnosis and DOAC or warfarin use at enrolment. Among 32275 eligible patients, 12116 (37.5%) had been diagnosed with HF. Patients with HF had significantly higher rates of HF hospitalization or cardiovascular death (HR 1.94, P<0.001), cardiovascular events (HR 1.59, P<0.001), cardiovascular death (HR 1.49, P<0.001), all-cause death (HR 1.32, P<0.001), and net clinical outcome including stroke/systemic embolism, major bleeding, and all-cause death (HR 1.23, P<0.001), compared with those without HF; however, HRs for stroke/systemic embolism (HR 0.96, P=0.56) and major bleeding (HR 1.14, P=0.13) were similar. DOAC use was associated with a low risk of stroke/systemic embolism (HR 0.86, P=0.19 in HF; HR 0.79, P=0.016 in non-HF; P for interaction=0.56), major bleeding (HR 0.71, P=0.008 in HF; HR 0.75, P=0.016 in non-HF; P for interaction=0.74), HF hospitalization or cardiovascular death (HR 0.81, P<0.001 in HF; HR 0.78, P<0.001 in non-HF; P for interaction=0.26), cardiovascular events (HR 0.83, P<0.001 in HF; HR 0.82, P=0.001 in non-HF; P for interaction=0.65), cardiovascular death (HR 0.84, P=0.12 in HF; HR 0.75, P=0.035 in non-HF; P for interaction=0.18), all-cause death (HR 0.89, P=0.082 in HF; HR 0.80, P=0.001 in non-HF; P for interaction=0.091), and net clinical outcome (HR 0.88, P=0.019 in HF; HR 0.81, P<0.001 in non-HF; P for interaction=0.21) compared with warfarin, irrespective of the presence or absence of HF. Analysis using the propensity score matching method showed similar associations. Non-valvular AF patients aged ≥75years with a history of HF had higher risks of cardiovascular events and mortality. DOACs were favourable to warfarin regardless of the coexistence of HF. These results might encourage the use of DOACs in elderly patients with non-valvular AF with or without HF.

Optimal Dose of Edoxaban for Very Elderly Atrial Fibrillation Patients at High Risk of Bleeding: The LEDIOS Registry.

Optimal anticoagulation in very elderly patients is challenging due to the high risk of anticoagulant-induced bleeding. The aim of this study was to assess outcomes of on-label reduced-dose edoxaban (30 mg) in very elderly patients who had additional risk factors for bleeding. This was a multi-center, prospective, non-interventional observational study to evaluate the efficacy and safety of on-label reduced-dose edoxaban in atrial fibrillation (AF) patients 80 years of age or older and who had more than 1 risk factor for bleeding. A total of 2448 patients (mean age 75.0±8.3 years, 801 [32.7%] males) was included in the present study, and 586 (23.9%) were 80 years of age or older with additional risk factors for bleeding. Major bleeding events occurred frequently among very elderly AF patients who had additional bleeding risk factors compared to other patients (unadjusted hazard ratio [HR], 2.16; 95% confidence interval [CI], 1.16-4.02); however, there were no significant differences in stroke incidence (HR, 1.86; 95% CI, 0.98-3.55). There were no significant differences for either factor after adjusting for age and sex (adjusted HR, 1.65; 95% CI, 0.75-3.62 for major bleeding; adjusted HR, 1.13; 95% CI, 0.51-2.50 for stroke). In very elderly AF patients with comorbidities associated with greater risk of bleeding, the incidence of major bleeding events was significantly increased. In addition, risk of stroke showed tendency to increase in same population. Effective anticoagulation therapy might be important in these high-risk population, and close observation of bleeding events might also be required. ClinicalTrials.gov Identifier: NCT03554837.

Factors influencing early recurrence of atrial fibrillation among elderly patients following radiofrequency catheter ablation and the impact of different antiarrhythmic regimens.

Patients with atrial fibrillation (AF) who undergo radiofrequency catheter ablation (RFCA) necessitate the administration of antiarrhythmic drugs to prevent early recurrence. The clinical outcomes among these patients may be influenced by varying antiarrhythmic regimens. To identify the risk factors associated with early recurrence and compare the clinical outcomes among different antiarrhythmic regimens in elderly patients with AF following radiofrequency catheter ablation (RFCA) during a 3-month period. A retrospective observational study encompassed 420 elderly patients with AF following RFCA. Baseline data were collected during the initial postoperative visit and clinical outcomes were carefully monitored over a 3-month follow-up period. Logistic regression and Cox-proportional hazard regression analyses were performed to investigate the relationship between various antiarrhythmic regimens and the clinical outcomes. Multivariate logistic regression analysis revealed that age (p = 0.001), left atrial diameter (p < 0.001), left ventricular diameter (p = 0.015), reactive hyperemia index (RHI) (p < 0.001), antiarrhythmic drug (p < 0.001) and hs-cTnI (p = 0.017) were independent risk factors of early recurrence. Furthermore, in cox survival regression analysis model, survival rate of early recurrence in the amiodarone group was higher than in the propafenone group (HR 2.30, 95%CI 1.17-4.53, p = 0.016) and in the sotalol group (HR 3.60, 95%CI 2.17-5.95, p < 0.001). Compared to the amiodarone group, the incidence of liver dysfunction was lower in the dronedarone group (p = 0.046) and the propafenone group (p = 0.021). The incidence of bradyarrhythmia (p = 0.003), QT interval prolongation (p = 0.035) and atrioventricular transmission block (p = 0.021) were higher in the sotalol group than in the amiodarone group. RHI was identified as an independent risk factor for early recurrence among elderly AF patients after RFCA. Compared to amiodarone, propafenone and sotalol exhibited an elevated risk of early recurrence. Although there was no significant difference in early recurrence between amiodarone and dronedarone, dronedarone emerged as the preferred option due to its lower frequency of adverse drug reactions than amiodarone.

Involvement of plasminogen activator inhibitor-1 in p300/p53-mediated age-related atrial fibrosis.

Plasminogen activator inhibitor-1 (PAI-1), a key regulator of the fibrinolytic system, is also intimately involved in the fibrosis. Although PAI-1 may be involved in the occurrence of atrial fibrillation (AF) and thrombosis in the elderly, but whether it participated in aging-related atrial fibrosis and the detailed mechanism is still unclear. We compared the transcriptomics data of young (passage 4) versus senescent (passage 14) human atrial fibroblasts and found that PAI-1 was closely related to aging-related fibrosis. Aged mice and senescent human and mouse atrial fibroblasts underwent electrophysiological and biochemical studies. We found that p300, p53, and PAI-1 protein expressions were increased in the atrial tissue of aged mice and senescent human and mouse atrial fibroblasts. Curcumin or C646 (p300 inhibitor), or p300 knockdown inhibited the expression of PAI-1 contributing to reduced atrial fibroblasts senescence, atrial fibrosis, and the AF inducibility. Furthermore, p53 knockdown decreased the protein expression of PAI-1 and p21 in senescent human and mouse atrial fibroblasts. Our results suggest that p300/p53/PAI-1 signaling pathway participates in the mechanism of atrial fibrosis induced by aging, which provides new sights into the treatment of elderly AF.

Abstract 13542: Electrical Delay, LA Electromechanical Delay, and LA Volume Contribute to Increased LA Stiffness in Relatively Elderly Patients With Pulmonary Vein Isolation for Atrial Fibrillation

Background: Atrial dysfunction occurs after pulmonary vein isolation (PVI) for atrial fibrillation (AF), and some reports suggest that electrical conduction delay (ECD) via the Bachmann bundle could be a contributing factor. However, the relationship between ECD in the atria and LA function after PVI remains unclear. The LA reservoir strain (LARS) by speckle-tracking echocardiography (STE) is used to assess LA booster function, with a decrease indicating increased LA stiffness. Purpose: We aim to investigate ECD, LA electromechanical delay (LAEMD), and LA function in patients after PVI for AF. Methods: This single-center retrospective study included 74 patients (Mean age at 70.4 ± 9.1 years, 44 males, left ventricular ejection fraction (LVEF): 62.9 ± 6.8 %, LA volume index: LAVI 39.0 ± 10.8 ml/m 2 ) who were in sinus rhythm at the echocardiographic examination. ECD on the ECG was defined as the presence of biphasic P waves, which were classified into those not observed (group A; n=42), those observed only in III lead (group B; n=23), and those observed in all lower wall leads (II, III, aVF) (group C; n=9). LAEMD was defined as the time interval between the top of the R wave on the ECG and the start of the late diastolic wave (a') on the tissue doppler imaging, and the lateral (a' lateral) and septum (a' septum) time differences (a’ sep-lat time) were calculated. To evaluate the LA function, two-dimensional STE was analyzed. Results: Mean observation period was 19.2 months after PVI. Groups B and C showed significant differences in a' sep-lat time compared to group A. LARS was markedly reduced in all groups (average: 19.0 ± 6.3). LARS and LAVI showed a significant difference between groups A and C. Multivariate analysis of factors leading to LARS showed correlations with a', E/e'. Conclusion: These results suggest that in relatively elderly post-PVI AF patients with preserved LVEF, the ECD and LAEMD as well as LAVI may affect LA function long after PVI and contribute to increased LA stiffness.

Abstract 12840: Left Atrial Enlargement is a Useful Predictor for Incident Heart Failure in Atrial Fibrillation Patients Without Pre-Existing Heart Failure

Background: Atrial fibrillation (AF) increases the risk of heart failure (HF). However, little focus has been placed on the risk stratification for HF in AF patients. Hypothesis: Left atrial diameter (LAD) is a simple prognostic parameter in patients with HF. We hypothesized that LAD is a useful predictor for incident HF in AF patients even without pre-existing HF. Methods: The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Japan. After excluding patients with pre-existing HF (defined as having one of the following; prior HF hospitalization, New York Heart Association class ≥2, or left ventricular ejection fraction &lt;40%), we investigated 2,464 patients with the data of LAD at enrollment. We divided the patients into 4 groups stratified by LAD (&lt;40 mm, 40-44 mm, 45-49 mm, and ≥50 mm), and compared the backgrounds and incidence of HF hospitalization between the groups. Results: Of 2,464 patients (mean age: 72±11 years, female: 919 [37%], paroxysmal AF: 1,405 [57%], and mean CHA2DS2-VASc score: 3.0±1.6), the mean LAD was 42±8 mm (&lt;40 mm: 1007 [41%], 40-44 mm: 650 [26%], 45-49 mm: 467 [19%] and ≥50 mm: 340 [14%], respectively). Patients with larger LAD had a higher prevalence of elderly and non-paroxysmal AF, and had a higher CHA2DS2-VASc score (all P&lt;0.001). During the median follow-up of 6.0 years, 260 patients (11%) were hospitalized for HF (annual incidence: 1.8% per person-year). Kaplan-Meier curves revealed that LAD was able to stratify the incidence of HF hospitalization in AF patients without HF (Figure). Multivariable Cox regression analysis demonstrated that larger LAD were independently associated with the risk of HF after adjustment by age, sex, AF type, and CHA2DS2-VASc score (Figure). Conclusion: Larger LAD was significantly associated with the higher incidence of HF hospitalization in AF without pre-existing HF, suggesting the utility of LAD regarding the risk stratification for HF in these patients.

Abstract 14204: Efficacy and Safety of Low-Dose Edoxaban According to Body Weight in Very Elderly Patients With Atrial Fibrillation: A Sub-Analysis of the ELDERCARE-AF Trial

Background: The ELDERCARE-AF trial showed that low-dose edoxaban is beneficial in elderly patients with non-valvular atrial fibrillation (AF) who are considered ineligible candidates for standard oral anticoagulants (OACs) due to high bleeding risk, but it was not known whether this is the case in low-body-weight patients. Methods: This was a prespecified sub-analysis, by body weight (≤45 and &gt;45 kg), of the ELDERCARE-AF trial, a randomized, placebo-controlled trial comparing low-dose edoxaban (15 mg once daily) with placebo. All patients were of Japanese ethnicity and considered ineligible for standard doses of OACs. The primary efficacy endpoint was stroke or systemic embolism (SSE). The key secondary endpoints were all-cause mortality and net clinical outcome. The primary safety endpoint was major bleeding according to the definition of the International Society on Thrombosis and Hemostasis. Results: Of the 984 patients, 374 patients (38.0%) were in the ≤45 kg group and 610 (62.0%) patients were in the &gt;45 kg group. The SSE was lower with edoxaban than with placebo in both weight groups (≤45 kg group: hazard ratio [HR] 0.36, 95% confidence interval [CI] 0.16-0.80; &gt;45 kg group: HR 0.31, 95% CI 0.13-0.73; interaction P 0.82). Both all-cause mortality and net clinical outcome were higher in the ≤45 kg group, with no significant difference between treatment groups. Major bleeding was numerically higher with edoxaban than with placebo (≤45 kg group: HR 3.05, 95% CI 0.84-11.11; &gt;45 kg group: HR 1.40, 95% CI 0.56-3.48), with no interaction with body weight (interaction P 0.33). Similar results were obtained in the exploratory analysis of patients divided into four quartiles of body weight (&gt;57.9, &gt;49.0 to ≤57.9, &gt;42.0 to ≤49.0, and ≤42.0 kg). Conclusions: The benefit of edoxaban 15 mg was consistent in elderly AF patients with low body weight, provided clinicians remain vigilant about the risk of major bleeding.

Safety and efficacy of ablation index-guided atrial fibrillation ablation in octogenarians.

Limited data on the efficacy and safety of atrial fibrillation (AF) ablation using an ablation index (AI) for octogenarians is available. We aimed to compare the efficacy and safety of AI-guided AF ablation between AF patients aged ≥80 years (Group 1) and <80 (Group 2). We hypothesized that AI-guided AF ablation could complete the procedure with comparable efficiency and safety in patients aged ≥80 years and <80. We retrospectively reviewed 2087 AF patients undergoing their first AI-guided AF ablation in our hospital. We compared the atrial tachyarrhythmia (AT) recurrence and procedure-related complication rate between Group 1 (n = 193) and Group 2 (n = 1894). The mean age was 83.0 (interquartile range [IQR] 81.0, 84.0) years in Group 1 and 67.0 (IQR 60.0, 72.0) in Group 2. AF type was significantly different between the two groups: Of Group 1 patients, 120 (62.2%) had paroxysmal AF, 61 (31.6%) persistent AF, and 12 (6.2%) long-standing persistent AF, while of Group 2 patients, 1016 (53.6%) paroxysmal AF, 582 (30.7%) persistent AF, and 296 (15.6%) long-standing persistent AF (p = .001). Unadjusted AT recurrence-free survival curves showed similar AT recurrence-free survival between the two groups (p = .67 by log-rank test). After the adjustment for AF type, the survival curve was similar between them (hazard ratio, 1.24; 95% CI [0.92-1.65]; p = .15, Group 1 vs. Group 2). The rate of procedure-related complications was similar between the two groups (3.1% vs. 3.0%, respectively, p = .83). Catheter ablation guided by AI achieved similar AT recurrence and complication rates between elderly AF patients aged ≥80 years and patients <80 years.

Assessment of DOAC in GEriatrics (Adage Study): Rivaroxaban/Apixaban Concentrations and Thrombin Generation Profiles in NVAF Very Elderly Patients.

Although a growing number of very elderly patients with atrial fibrillation (AF), multiple conditions, and polypharmacy receive direct oral anticoagulants (DOACs), few studies specifically investigated both apixaban/rivaroxaban pharmacokinetics and pharmacodynamics in such patients. To investigate: (1) DOAC concentration-time profiles; (2) thrombin generation (TG); and (3) clinical outcomes 6 months after inclusion in very elderly AF in-patients receiving rivaroxaban or apixaban. Adage-NCT02464488 was an academic prospective exploratory multicenter study, enrolling AF in-patients aged ≥80 years, receiving DOAC for at least 4 days. Each patient had one to five blood samples at different time points over 20 days. DOAC concentrations were determined using chromogenic assays. TG was investigated using ST-Genesia (STG-ThromboScreen, STG-DrugScreen). We included 215 patients (women 71.1%, mean age: 87 ± 4 years), 104 rivaroxaban and 111 apixaban, and 79.5% receiving reduced-dose regimen. We observed important inter-individual variabilities (coefficient of variation) whatever the regimen, at C max [49-46%] and C min [75-61%] in 15 mg rivaroxaban and 2.5 mg apixaban patients, respectively. The dose regimen was associated with C max and C min plasma concentrations in apixaban (p = 0.0058 and p = 0.0222, respectively), but not in rivaroxaban samples (multivariate analysis). Moreover, substantial variability of thrombin peak height (STG-ThromboScreen) was noticed at a given plasma concentration for both xabans, suggesting an impact of the underlying coagulation status on TG in elderly in-patients. After 6-month follow-up, major bleeding/thromboembolic event/death rates were 6.7%/1.0%/17.3% in rivaroxaban and 5.4%/3.6%/18.9% in apixaban patients, respectively. Our study provides original data in very elderly patients receiving DOAC in a real-life setting, showing great inter-individual variability in plasma concentrations and TG parameters. Further research is needed to understand the potential clinical impact of these findings.

Prognostic impact of heart rate during atrial fibrillation on clinical outcomes in elderly non-valvular atrial fibrillation patients: ANAFIE Registry sub-cohort study

BackgroundElderly patients with atrial fibrillation (AF) are at a higher risk for all-cause mortality and heart failure. Rate control is an essential component in AF management. This exploratory study assessed the relationship between resting heart rate during AF at baseline and clinical outcomes in Japanese elderly non-valvular AF (NVAF) patients, using the All Nippon AF In the Elderly Registry (ANAFIE) dataset. MethodsThis sub-cohort included patients who agreed to participate and presented with AF at enrollment in the ANAFIE study. They were categorized into six groups according to the resting heart rate during AF. Outcomes included 2-year cumulative incidences of stroke/systemic embolic events (SEE), ischemic stroke, major bleeding, cardiovascular (CV) events, CV death, all-cause death, and net clinical outcome, a composite of stroke/SEE, major bleeding, and all-cause death. ResultsOf the 8292 patients included in this sub-cohort (paroxysmal, 1496; non-paroxysmal, 6796), 90 % of patients were using anticoagulants. Higher heart rate was more frequently reported in women and in patients with paroxysmal AF and was associated with increased use of direct oral anticoagulants (DOACs) and antiarrhythmic drugs. Heart rate ≥110 beats per minute (bpm) was associated with a significantly higher incidence of cardiac events and numerically higher incidences of CV death and all-cause death compared with a heart rate of 60 to <80 bpm, all of which were driven by an increased risk in patients with non-paroxysmal AF. Hazard ratios by the type of anticoagulant for each clinical outcome were comparable across all heart rate categories, indicating no significant interactions. ConclusionsElderly Japanese patients with non-paroxysmal NVAF and a heart rate ≥110 bpm have an increased risk of cardiac events. There was no interaction between heart rate category and the relative risk of adverse clinical events in patients taking DOACs compared with those taking warfarin.

Mobile health-technology integrated care in elderly atrial fibrillation patients: a report from the mAFA-II randomized clinical trial

Abstract Background The prospective Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) randomized trial demonstrated the efficacy of a mobile health (mHealth) technology implemented “Atrial fibrillation Better Care” (ABC) pathway approach (mAFA intervention) for holistic or integrated care management in reducing the risk of adverse events in in patients with atrial fibrillation (AF). Whether these benefits also apply to elderly patients (who may be less adoptive of mHealth approaches) is unclear. Purpose In this ancillary analysis of the mAFA-II trial, we evaluated the effect of the mAFA intervention among elderly AF patients (age ≥75 years). Methods The mAFA-II trial enrolled adults AF patients across 40 centres in China between June 1, 2018 and August 16, 2019. The main outcome was the composite outcome of stroke or thromboembolism, all-cause death, and rehospitalization. Effect of the mAFA intervention was assessed through Cox proportional hazard models after the adjustment for baseline risk factors and cluster effect. We also assessed the interaction between age and the mAFA intervention effect on the main trial population. Results In this analysis, 1,163 elderly AF patients (mean age: 82.6±5.3 years, 43.1% females) were included, of which 520 were allocated to mAFA intervention and 643 to usual care. The mAFA intervention was associated with a significant reduction of the composite outcome (adjusted hazard ratio [aHR]: 0.58, 95% CI: 0.35–0.97) and rehospitalizations alone (aHR: 0.47, 95% CI: 0.24–0.91). A significant interaction between age and mAFA allocation group was observed for both the composite outcome (p=0.002; Figure 1, Panel A) and rehospitalization alone (p=0.015; Figure 1, Panel B), with the beneficial effect of the mAFA intervention decreasing with increasingly higher age, particularly at age ≥80 years old. Conclusions A mHealth-technology implemented ABC pathway is effective in reducing adverse clinical events in older AF patients aged ≥75 years old. The benefits obtained with mAFA intervention were attenuated at extreme ages, especially in those aged ≥80 years old. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): This research was funded by the National Natural Science Foundation of China 82170309). This study was an investigator-initiated project, with limited funding by independent research and educational grants.

Antithrombotic treatment switching in elderly patients with atrial fibrillation and the risk of thromboembolism, bleeding, and cardiac death

BackgroundRisks of antithrombotic switching is not investigated in elderly atrial fibrillation patients. ObjectivesTo investigate the effectiveness and safety of antithrombotic treatment and switching of antithrombotic treatment in elderly patients (aged 75 years or older) with atrial fibrillation (AF). MethodsWe conducted a cohort study of 2943 patients with AF (Carrebean‐elderly), hospitalized during 2010–2017. Cox models were used to estimate the association of antithrombotic treatment (warfarin, direct oral anticoagulants [DOAC] and non–guideline‐recommended therapy [NG], i.e., aspirin and low‐molecular‐weight heparin) at discharge and antithrombotic treatment switching during follow‐up with the risk of a composite and single end points of thromboembolism, bleeding, and cardiac death. Crude and adjusted risk estimates were expressed as hazard ratios (HRs) with 95% confidence intervals (CIs). All‐cause death was evaluated, with competing risk regression and estimates expressed as subhazard ratios and 95% CIs. ResultsWe observed an increased risk for the composite end point associated with NG as compared to warfarin at discharge (HR, 1.18; 95% CI, 1.01–1.38) with congruent competing risk regression results, while no significant risk difference was seen for DOACs compared to warfarin (HR, 1.12; 95% CI, 0.92–1.36). Switching from NG to warfarin/DOAC and from warfarin to DOAC occurred in 30.4% and 33.1% of respective antithrombotic treatment groups at discharge and was associated with a decreased risk for the composite end point with an adjusted HR of 0.45 (95% CI, 0.32–0.63) and a HR of 0.50 (95% CI, 0.38–0.65), respectively. ConclusionsAntithrombotic treatment switching is common in the elderly AF population. Importantly, switching to guideline‐recommended treatment has a favorable impact on both effectiveness and safety.

1. Comprehensive Treatment of Atrial Fibrillation in Elderly and Very Elderly Patients

1. Comprehensive Treatment of Atrial Fibrillation in Elderly and Very Elderly Patients

Current Use of Oral Anticoagulation Therapy in Elderly Patients with Atrial Fibrillation: Results from an Italian Multicenter Prospective Study-The ISNEP Study.

Background: Atrial fibrillation (AF) is the most common heart arrhythmia, and its prevalence increases with age. Oral Anticoagulant Therapy (OAT) with non-vitamin K antagonist oral anticoagulants (NOACs) or vitamin K antagonists (VKAs) is essential to avoid thromboembolic events in AF. However, this treatment is associated with a high risk of bleeding and low adherence in elderly patients. Aim: The aim was to evaluate the real-world use of OAT in a population of patients aged ≥80 years in twenty-three Italian centers and to investigate the tolerance of and patient satisfaction with this therapy. Methods: The ISNEP Study is a multicenter cross-sectional study enrolling patients with AF and aged ≥80 years and treated with either NOACs or VKAs. A written questionnaire was administered to each patient to evaluate the adherence to and patient satisfaction with this therapy. Results: The study included 641 patients with a mean age of 85 (82–87) years. The use of NOACs was reported in 93.0% of cases, with the remaining 7.0% treated with VKAs. A history of stroke events was reported in five (11.1%) and one (0.2%) patients in the VKA and NOAC groups, respectively. The rate of referred ecchymosis/epistaxis was significantly higher in the VKA group compared to the NOAC group (p < 0.001). Patients receiving NOACs reported a substantial improvement in their quality of life compared to the VKA group. Conclusions: A small, but not negligible, proportion of elderly AF patients is still treated with VKAs. Patients treated with NOAC have a higher level of satisfaction with the therapy and complete adherence.

Association of advanced age with procedural complications and in-hospital outcomes from left atrial appendage occlusion device implantation in patients with atrial fibrillation: insights from the National Inpatient Sample of 36,065 procedures

BackgroundAge-stratified analyses of atrial fibrillation (AF) patients undergoing percutaneous left atrial appendage occlusion (LAAO) are limited. The purpose of current study was to compare in-hospital outcomes in elderly AF patients (age > 80 years) to a relatively younger cohort (age £ 80 years) after LAAO.MethodsData were extracted from National Inpatient Sample for calendar years 2015–2018. LAAO device implantations were identified on the basis of International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes of 37.90 and 02L73DK. The outcomes assessed in our study included complications, inpatient mortality, and resource utilization with LAAO.ResultsA total of 36,065 LAAO recipients were included in the final analysis, of which 34.6% (n=12,475) were performed on elderly AF patients. Elderly AF patients had a higher prevalence of major complications (6.7% vs. 5.7%, p < 0.01) and mortality (0.4% vs. 0.1%, p < 0.01) after LAAO device implantation in the crude analysis. After multivariate adjustment of potential confounders, age > 80 years was associated with increased risk of inpatient mortality (adjusted odds ratio [aOR] 4.439, 95% confidence interval [CI] 2.391–8.239) but not major complications (aOR 1.084, 95% CI 0.971–1.211), prolonged length of stay (aOR 0.943, 95% CI 0.88–1.101), or increased hospitalization costs (aOR 0.909, 95% CI 0.865–0.955).ConclusionOver 1 in 3 LAAO device implantations occurred in elderly AF patients. After adjusting for potential confounding variables, advanced age was associated with inpatient mortality, but not with other LAAO procedural–related outcomes including major complications, prolonged length of stay, or increased hospitalization costs.

Renal Function and Body Mass Index Contribute to Serum Neurofilament Light Chain Levels in Elderly Patients With Atrial Fibrillation.

ObjectiveSerum neurofilament light chain (sNfL) is increasingly used as a neuroaxonal injury biomarker in the elderly. Besides age, little is known about how other physiological factors like renal function and body mass index (BMI) alter its levels. Here, we investigated the association of estimated glomerular filtration rate (eGFR) and BMI with sNfL in a large sample of elderly patients with atrial fibrillation (AF).MethodsThis is a cross-sectional analysis from the Swiss-AF Cohort (NCT02105844). We measured sNfL using an ultrasensitive single-molecule array assay. We calculated eGFR using the chronic kidney disease epidemiology collaboration (CKD-EPI) creatinine (eGFRcrea) and creatinine–cystatin C (eGFRcrea–cys) formulas, and BMI from weight and height measurements. We evaluated the role of eGFR and BMI as determinants of sNfL levels using multivariable linear regression and the adjusted R2 (R2adj).ResultsAmong 2,277 Swiss-AF participants (mean age 73.3 years), eGFRcrea showed an inverse curvilinear association with sNfL after adjustment for age and cardiovascular comorbidities. BMI also showed an independent, inverse linear association with sNfL. The R2adj of models with age, eGFRcrea, and BMI alone was 0.26, 0.35, and 0.02, respectively. A model with age and eGFRcrea combined explained 45% of the sNfL variance. Sensitivity analyses (i) further adjusting for vascular brain lesions (N = 1,402 participants with MRI) and (ii) using eGFRcrea–cys yielded consistent results.InterpretationIn an elderly AF cohort, both renal function and BMI were associated with sNfL, but only renal function explained a substantial proportion of the sNfL variance. This should be taken into account when using sNfL in elderly patients or patients with cardiovascular disease.