Atrial Fibrillation In Older Patients Research Articles

A pooled analysis of the incidence and mortality risk of atrial fibrillation in patients with COVID-19.

There exist serious cardiovascular complications subsequent to SARS-Cov2 infection (COVID-19); however, the association between COVID-19 and atrial fibrillation (AF) remains to be elucidated. We aimed to assess the prevalence of AF among COVID-19 patients and its associated risk of death. The present systematic review was performed in accordance with the PRISMA guidelines. The protocol was registered with CRD42022306523. A comprehensive literature search was performed across PubMed, Embase, and Cochrane databases to identify studies reporting on the prevalence of pre-existing or new-onset fibrillation (AF), and/or the associated clinical outcomes in patients with COVID-19 from January 2020 to December 2023. The random-effect model was used to estimate the prevalence of AF and its related mortality. A total of 80 studies, including 39,062,868 COVID-19 patients, were identified in the present investigation. The prevalence rates of pre-existing AF or new-onset AF were 10.5% (95% CI [9.3-11.7%]) or 10.3% (95% CI [6.2-14.5%]), respectively. Subgroup analysis revealed a two fold higher incidence of AF in older patients (≥65 years) compared to younger patients (<65 years) (14.4% vs. 6.4%). The highest rate of AF was observed in Europeans (10.7%, 95% CI [10.2-11.2%]), followed by Northern Americans (10.0%, 95% CI [8.2-11.7%]), while Asians demonstrated a lower prevalence (2.7%, 95% CI [2.2-3.3%]). Notably, severe COVID-19 patients displayed a significantly elevated prevalence of AF at 14.l% (95% CI [13.3-14.9%]), which was approximately 2.5-fold higher than that in non-severe patients (5.2%, 95% CI [4.8-5.5%]). Both pre-existing (HR: 1.83, 95% CI [1.49-2.17]) and new-onset AF (HR: 3.47, 95% CI [2.26-5.33]) were associated with an increased mortality risk among COVID-19 patients. Furthermore, the effect on mortality risk was more significant in Asians (HR: 5.33, 95% CI [1.62-9.04]), compared to Europeans (HR: 1.68, 95% CI [1.24-2.13]) and North Americans (HR: 2.01, 95% CI [1.18-2.83]). This study comprehensively investigated the association between AF and COVID-19 in a real-world setting. Notably, a high prevalence of AF was observed among older individuals, severe COVID-19 patients, and in Europe and Northern America. Moreover, co-existing AF was found to be associated with an increased risk for mortality. Further investigations are warranted to improve the management and outcomes of COVID-19 patients with AF.

Enormous Burden of Atrial Fibrillation in Older Patients With Congenital Heart Disease: Do Only Age and Underlying Heart Defect Matter?

Enormous Burden of Atrial Fibrillation in Older Patients With Congenital Heart Disease: Do Only Age and Underlying Heart Defect Matter?

Cardioversion versus ablation versus ‘pace and ablate’ for persistent atrial fibrillation in older patients

Cardioversion versus ablation versus ‘pace and ablate’ for persistent atrial fibrillation in older patients

Metabolomics and frailty: a "from bench to bedside" approach to atrial fibrillation in older patients

Abstract Background Atrial fibrillation (AF) is the most common sustained arrhythmia diagnosed at an advanced age. The most important complications of AF are stroke, heart failure and dementia. The pathophysiology of the arrhythmia is complex and multifaceted and several aspects are still not completely understood. Purpose Our project aimed at exploring the molecular characteristics of AF in older patients using an untargeted metabolomics approach, an analytical technique that provides an insight of the global metabolic profile at an individual level. As secondary endpoints, we evaluated the association between metabolomics and acylcarnitines, which are mediators of myocyte electrical instability, and difference in metabolomics profile between healthy controls (C) and AF patients (AF-P). Method We evaluated 50 consecutive older AF-P with persistent AF, waiting to be treated with elective electrical cardioversion of the arrhythmia, and 22 healthy controls (C). In all patients, the cardiological evaluation was integrated with tools of the Geriatric Multidimensional Assessment (GMA) to describe neurocognitive function (Mini-Mental State Examination, MMSE), depressive symptoms (15-item Geriatric Depression Scale, GDS), and physical performance (Short Physical Performance Battery, SPPB). Interleukin-6 (IL-6), a marker of low-grade inflammation, was measured with ELISA assays. Metabolomics analysis and acylcarnitine measurements were carried out using gas chromatography coupled with mass spectrometry (GC-MS). Results AF-P and C did not differ by age (76 ± 6 vs. 70 ± 14 years, p = 0.055); patients had a lower proportion of women (AF-P: 32% vs. C: 64%, p = 0.012). Cluster analysis applied to metabolomic data in all population identified two subset of subjects, characterized by a different body mass index (BMI; 23.57 vs. 32.53 Kg/m², p = 0.046). When studying only the AF-P group, the simultaneous presence of a higher CHA2DS2-VASc score (4.17 ± 1.32 vs. 2.88 ± 1.83, p = 0.007), a lower physical function (SPPB; 8.97± 2.22 vs. 10.75 ± 1.13, p = 0.009), and higher IL-6 levels (4.42 vs. 2.39 pg/mL, p = 0.002) described the cluster with a worse clinical phenotype and a specific metabolomics pattern. Furthermore, an association between IL-6 and medium- long-chain acylcarnitines emerged (acylcarnitine 12:1, β = 31.7 ± 9.4, R = 0.446, p = 0.001). Conclusions Present analysis demonstrated that a specific metabolomics profile was characteristic of older AF patients with a frail phenotype, identified by higher CHA2DS2-VASc score and IL-6 concentration, and lower physical performance. Future studies are needed to reveal the single molecular pathways responsible of these behaviour, potentially useful to guide a targeted therapy. Last, inflammation per se could contribute to electrical instability in AF, while body mass index, a surrogate measure of undernutrition, could identify different metabolic pathways in controls and in patients with the arrhythmia.Metabolomics by clinical phenotypes

Predictive value of bleeding risk scores in elderly patients with atrial fibrillation and oral anticoagulation.

The predictive value of bleeding risk scores for atrial fibrillation in older patients is not as well known. The goal of this study was to evaluate the predictive value of HASBLED, ORBIT and ATRIA for major bleeding (MB) and intracranial hemorrhage (ICH) in patients ≥ 75 years with atrial fibrillation and oral anticoagulation (OAC). A retrospective unicenter study including patients ≥ 75 years with atrial fibrillation (AF) and OAC. A total of 7613 patients ≥ 75 years with AF and OAC included between 2014 and 2018 (registry: NCT04364516). We analyzed the discriminative value of HASBLED, ATRIA and ORBIT scores for bleeding endpoints (major bleeding as primary endpoint and intracerebral hemorrhage as secondary). Cox regression was used to predict major bleeding with each scale and also for searching other variables potentially predictor of major bleeding. Model discrimination was assessed using Harrell's C-statistic. Calibration was assessed with goodness-of-fit test proposed by Gronnesby and Borgan. During a mean follow up of 4.0 years (IQR: 2.4-5.7 years), 729 patients developed MB (2.61 per 100 patients/year) and 243 patients developed ICH (0.85 per 100 patients/year). Three scores showed a low discrimination for major bleeding, being ORBIT the best (HASBLED C statistic = 0.557; ATRIA C statistic = 0.568; ORBIT C statistic = 0.595) and also a low discrimination for ICH (HASBLED C statistic = 0.509; ATRIA C statistic = 0.522; ORBIT C statistic = 0.526). Among the variables that are part of the scores and other baseline characteristics, after multivariable adjustment only sex (male), dementia, prior admission for bleeding, anemia and liver disease were found as a predictors of MB. In older patients under oral anticoagulation with atrial fibrillation, the risk scores HASBLED, ATRIA and ORBIT showed a weak discrimination for major bleeding and intracranial hemorrhage. Therefore, other better alternatives should be evaluated for this purpose.

Modifiable factors associated with postoperative atrial fibrillation in older patients with hip fracture in an orthogeriatric care pathway: a nested case–control study

BackgroundFew data are available regarding post-operative atrial fibrillation (POAF) in non-cardiothoracic surgery, particularly orthopedic surgery. Hence, given the frequent incidence of POAF after surgery and its marked impact, we need to identify modifiable factors associated with POAF after hip fracture surgery in older patients.MethodsWe conducted a nested case–control study in the unit for perioperative geriatric care of an academic hospital in Paris from July 1, 2009 to December 31, 2019, enrolling all consecutive patients aged ≥ 70 years with hip fracture surgery and no history of permanent AF before admission (retrospective analysis of prospectively collected data). Patients with and without POAF were matched 1:5 on 5 baseline characteristics (age, hypertension, diabetes, coronary artery disease, cardiac failure).ResultsOf the 757 patients included, 384 were matched, and 64 had POAF. The incidence of POAF was 8.5%. The mean age was 86 ± 6 years, 298 (78%) patients were female, and the median Charlson Comorbidity Index was 6 (interquartile range 4–8). The median time from surgery to the occurrence of POAF was 2 days (1–4). On multivariable conditional logistic regression analysis (matched cohort), the modifiable factors present at admission associated with POAF were time to surgery > 48 h (odds ratio [OR] = 1.66, 95% confidence interval [1.01–2.81]) and > 2 units of packed red blood cells (OR = 3.94, [1.50–10.03]).ConclusionsThis study provides new information about POAF in older patients with hip fracture surgery, a surgical emergency whose complexity requires multidisciplinary care.

Prevalence and factors associated with atrial fibrillation in older patients with obstructive sleep apnea

PurposeThis study sought to identify the prevalence and factors associated with atrial fibrillation (AF) in older patients with obstructive sleep apnea (OSA) in China. MethodsThis was an explorative cross-sectional study. Between January 2015 and October 2017, we continuously recruited 1285 older patients with OSA who underwent overnight polysomnography from sleep centers of multiple hospitals. They were assessed using 12-lead ECG or 24-h dynamic ECG, and their baseline demographics, clinical characteristics, sleep parameters, and medical history were determined. Multivariate binary logistic regression analysis was used to investigate the factors related to AF in these older patients with OSA.ResultsThe clinician classified 122 (9.5%) patients as having AF. The prevalence of AF significantly increased with age (P < 0.05) but did not significantly differ between the mild, moderate, and severe OSA groups. Additionally, the prevalence of paroxysmal AF was 7.2% among the overall study population, and it increased with OSA severity or advanced age (P < 0.05). Persistent AF was noted in 2.3% participants, and the prevalence also increased with age. The logistic regression analysis showed that age (OR = 1.054, 95%CI: 1.027–1.018, P < 0.001), history of drinking (OR = 1.752, 95%CI: 1.070–2.867, P < 0.05), chronic heart disease (OR = 1.778, 95%CI: 1.156–2.736, P < 0.01), diabetes mellitus (OR = 1.792, 95%CI: 1.183–2.713, P < 0.01), and reduced diastolic function (OR = 2.373, 95%CI = 1.298–4.337, P < 0.01) were relevant to AF among participants with OSA.ConclusionThe prevalence of AF is significantly common in older patients with OSA. Age, history of drinking, chronic heart disease, diabetes mellitus, and reduced diastolic function are independently related to AF in these patients.

Atrial fibrillation in older adults with cancer.

Cancer and atrial fibrillation (AF) are common co-morbid conditions in older adults. Both cancer and cancer treatment increase the risk of developing new AF which increases morbidity and mortality. Heart rate and rhythm control along with anticoagulation therapy remain the mainstay of treatment of AF in older adults with both cancer and AF. Adjustments to the treatment may be necessary because of drug interactions with concurrent chemotherapy. Cancer and old age increase the risk of both, thromboembolism and bleeding. The risk of these complications is further enhanced by concomitant cancer therapy, frailty, poor nutrition status and, coexisting geriatric syndromes. Therefore, careful attention needs to be given to the risks and benefits of using anticoagulant medications. This review focuses on the management of AF in older patients with cancer, including at the end-of-life care.

509 A biochemical approach to atrial fibrillation in older patients

Abstract Aims Atrial fibrillation (AF) is the most common arrhythmia among the elderly. It is characterized by a disordered electrical activity of the atria and is associated with increased morbidity and mortality. The pathogenesis of AF is not completely understood as it depends on a multifactorial combination of electrical and structural remodelling and inflammation. Metabolomics is the study of the small molecules present in a given biological sample and it has been widely used to determine the metabolic signatures of certain diseases. Untargeted metabolomics consists of a comprehensive screening of all measurable metabolites to identify patterns related to a certain disease, while targeted metabolomics aims at analysing a defined group of metabolites belonging to a specific metabolic pathway or class of compounds. Mass spectrometry (MS), coupled with gas chromatography (GC) and liquid chromatography (LC) offers the possibility of performing quantitative analyses with high selectivity and sensitivity. Aims of this project were to understand the biomolecular mechanisms underlying the onset of AF. Methods We compared plasma samples of older patients with AF with those of healthy subjects. We started from untargeted metabolomics to explore the whole metabolome; then we focused on the lipidomic profile, and, finally, we measured the plasma concentration of acylcarnitines and some amino acids, known to be diagnostic markers of certain metabolic diseases. Fifty patients (age: 76 ± 6 years) and 26 healthy subjects (age: 65 ±19 years) were recruited for the study. A blood sample was drawn by each patient. Samples for metabolomics and lipidomics were processed, respectively, with a GC-MS platform and with high-resolution LC-MS. Results Differences in diseased and healthy metabolomic and lipidomic profiles were not detected, while the concentration of some acylcarnitines and amino acids resulted to be significantly different in the two groups. In particular, two long-chain acylcarnitines (LCACs), C14 and C18:1, were more abundant in the plasma of AF patients, while glycine, which has scavenger properties, had a lower concentration. High levels of circulating LCACs have been associated with cardiovascular diseases and they are known to alter the heart electrophysiology, thus representing a possible marker of the development of arrhythmias. We can hypothesize that the different concentrations we found possibly reflect a higher oxidative and metabolic stress induced by the arrhythmia. Conclusions The alterations of the LCACs we found in AF patients could represent the basis to guide specific therapeutic interventions aimed at reducing the incidence of the hemodynamic and embolic complications of the arrhythmia. In particular, recent guidelines for the management of AF patients introduced the acronym ABC, which means ‘Avoid stroke’—A, ‘Better symptoms management’—B, and ‘Cardiovascular risk and comorbidity management’—C. In this sense, the present research represents an attempt to join and enrich the traditional clinical approach with data derived from laboratory activity, to improve the outcome of the oldest segment of cardiac patients, often presenting rhythm alterations.

COVID-19 and Atrial Fibrillation in Older Patients: Does Oral Anticoagulant Therapy Provide a Survival Benefit?-An Insight from the GeroCovid Registry.

Atrial fibrillation (AF), the most frequent arrhythmia of older patients, associates with serious thromboembolic complications and high mortality. Coronavirus disease 2019 (COVID-19) severely affects aged subjects, determining an important prothrombotic status. The aim of this study was to evaluate mortality-related factors in older AF patients with COVID-19. Between March and June 2020, we enrolled ≥60 year-old in-hospital COVID-19 patients (n = 806) in GeroCovid, a multicenter observational study promoted by the Italian Society of Gerontology and Geriatric Medicine. The prevalence of AF was 21.8%. In-hospital mortality was higher in the AF group (36.9 vs. 27.5%, p = 0.015). At admission, 51.7, 10.2, and 38.1% of AF cases were taking, respectively, oral anticoagulants (OACs), antiplatelet agents, and no antithrombotic therapy. During hospitalization, 51% patients switched to low-molecular-weight heparins. AF patients who survived were younger (81 ± 8 vs. 84 ± 7 years; p = 0.002) and had a lower CHA2DS2-VASc score (3.9 ± 1.6 vs. 4.4 ± 1.3; p = 0.02) than those who died. OAC use before (63.1 vs. 32.3%; p < 0.001) and during hospitalization (34.0 vs. 12.7%; p = 0.002) was higher among survivors. At multivariable analysis, lower age, higher self-sufficiency, less severe initial COVID-19 presentation, and the use of vitamin K antagonists (odds ratio [OR] = 0.16, 95% confidence interval [CI]: 0.03-0.84) or direct OACs (OR = 0.22, 95% CI: 0.08-0.56) at admission, or the persistence of OAC during hospitalization (OR = 0.05, 95% CI: 0.01-0.24), were associated with a lower chance of in-hospital death. AF is a prevalent and severe condition in older COVID-19 patients. Advanced age, dependency, and relevant clinical manifestations of disease characterized a worse prognosis. Preadmission and in-hospital anticoagulant therapies were positively associated with survival.

Management of Atrial Fibrillation in Older Patients by Morbidity Burden: Insights From Get With The Guidelines-Atrial Fibrillation.

BackgroundKnowledge is scarce regarding how multimorbidity is associated with therapeutic decisions regarding oral anticoagulants (OACs) in patients with atrial fibrillation.Methods and ResultsWe conducted a cross‐sectional study of hospitalized patients with atrial fibrillation using the Get With The Guidelines‐Atrial Fibrillation registry from 2013 to 2019. We identified patients ≥65 years and eligible for OAC therapy. Using 16 available comorbidity categories, patients were stratified by morbidity burden. A multivariable logistic regression model was used to determine the odds of receiving OAC prescription at discharge by morbidity burden. We included 34 174 patients with a median (interquartile range) age of 76 (71–83) years, 56.6% women, and 41.9% were not anticoagulated at admission. Of these patients, 38.6% had 0 to 2 comorbidities, 50.7% had 3 to 5 comorbidities, and 10.7% had ≥6 comorbidities. The overall discharge OAC prescription was high (85.6%). The prevalence of patients with multimorbidity increased from 59.7% in 2014 to 64.3% in 2019 (P trend=0.002). Using 0 to 2 comorbidities as the reference, the adjusted odds ratio (95% CI) of OAC prescription were 0.93 (0.82, 1.05) for patients with 3 to 5 comorbidities and 0.72 (0.60, 0.86) for patients with ≥6 comorbidities. In those with ≥6 comorbidities, the most common reason for nonprescription of OACs were frequent falls/frailty (31.0%).ConclusionsIn a contemporary quality‐of‐care database of hospitalized patients with atrial fibrillation eligible for OAC therapy, multimorbidity was common. A higher morbidity burden was associated with a lower odds of OAC prescription. This highlights the need for interventions to improve adherence to guideline‐recommended anticoagulation in multimorbid patients with atrial fibrillation.

Atrial fibrillation in older patients and artificial intelligence: a quantitative demonstration of a link with some of the geriatric multidimensional assessment tools-a preliminary report.

Atrial fibrillation (AF) associates with disability and frailty. Aim of this study was to evaluate in older AF patients, using artificial intelligence (AI), the relations between geriatric tools and daily standing and resting periods. We enrolled thirty-one > 65years patients undergoing electrical cardioversion of AF (age: 79 ± 6years; women: 41.9%; CHA2DS2-VASc: 3.7 ± 1.2; MMSE: 27.7 ± 2.7; GDS: 3.0 ± 2.8). The data of the first day following the procedure were analyzed using machine-learning techniques in a specifically designed cloud platform. Standing, activity, time (582 ± 139min) was directly associated with MMSE and inversely with GDS. Sleep length was 472 ± 230min. Light sleep, the longer resting phase, was inversely related to GDS. The Chest Effort Index, a measure of obstructive sleep apnea, grew with GDS. In conclusion, AI devices can be routinely used in improving older subjects' evaluation. A correlation exists between standing time, MMSE, and depressive symptoms. GDS associates to length and quality of sleep.

Cost-effectiveness of antithrombotic agents for atrial fibrillation in older adults at risk for falls: a mathematical modelling study.

Antithrombotic drugs decrease stroke risk in patients with atrial fibrillation, but they increase bleeding risk, particularly in older adults at high risk for falls. We aimed to determine the most cost-effective antithrombotic therapy in older adults with atrial fibrillation who are at high risk for falls. We conducted a mathematical modelling study from July 2019 to March 2020 based on the Ontario, Canada, health care system. We derived the base-case age, sex and fall risk distribution from a published cohort of older adults at risk for falls, and the bleeding and stroke risk parameters from an atrial fibrillation trial population. Using a probabilistic microsimulation Markov decision model, we calculated quality-adjusted life years (QALYs), total cost and incremental cost-effectiveness ratios (ICERs) for each of acetylsalicylic acid (ASA), warfarin, apixaban, dabigatran, rivaroxaban and edoxaban. Cost data were adjusted for inflation to 2018 values. The analysis used the Ontario public payer perspective with a lifetime horizon. In our model, the most cost-effective antithrombotic therapy for atrial fibrillation in older patients at risk for falls was apixaban, with an ICER of $8517 per QALY gained (5.86 QALYs at $92 056) over ASA. It was a dominant strategy over warfarin and the other antithrombotic agents. There was moderate uncertainty in cost-effectiveness ranking, with apixaban as the preferred choice in 66% of model iterations (given willingness to pay of $50 000 per QALY gained); edoxaban, 30 mg, was preferred in 31% of iterations. Sensitivity analysis across ranges of age, bleeding risk and fall risk still favoured apixaban over the other medications. From a public payer perspective, apixaban is the most cost-effective antithrombotic agent in older adults at high risk for falls. Health care funders should implement strategies to encourage use of the most cost-effective medication in this population.

A Structured Literature Review and International Consensus Validation of FORTA Labels of Oral Anticoagulants for Long-Term Treatment of Atrial Fibrillation in Older Patients (OAC-FORTA 2019).

IntroductionEvidence regarding safety and efficacy of oral anticoagulants for the treatment of atrial fibrillation (AFib) in older adults has been assessed regarding the age appropriateness of oral anticoagulants (OAC) according to the FORTA (Fit fOR The Aged) classification (OAC-FORTA). Three years after its first version (OAC-FORTA 2016), an update was initiated to create OAC-FORTA 2019.MethodsA structured review of randomized controlled clinical trials and summaries of individual product characteristics was performed to detect newly emerged evidence on oral anticoagulants in older patients with AFib. This review was used by an interdisciplinary panel of European experts (N = 10) in a Delphi process to label OACs according to FORTA.ResultsA total of 202 records were identified and 11 studies finally included. We found four new trials providing relevant data on efficacy and safety of warfarin, apixaban, dabigatran or rivaroxaban in older patients with AFib. In the majority of studies comparing the non-vitamin-K oral anticoagulants (NOACs) with warfarin, NOACs were superior to warfarin regarding at least one relevant clinical endpoint. The mean consensus coefficient significantly increased from 0.867 (OAC-FORTA 2016) to 0.931 (p < 0.05) and the proposed FORTA classes were confirmed in all cases during the first round (consensus coefficient > 0.8). Warfarin, dabigatran, edoxaban and rivaroxaban were assigned to the FORTA B label, acenocoumarol, fluindione and phenprocoumon were labeled FORTA C and only apixaban was rated as FORTA A.ConclusionOAC-FORTA 2019 confirms that AFib can be successfully treated with positively labeled antithrombotics at advanced age.Electronic supplementary materialThe online version of this article (10.1007/s40266-020-00771-0) contains supplementary material, which is available to authorized users.

Atrial Fibrillation in Older Patients with Syncope and Dementia: Insights from the Syncope and Dementia Registry

ObjectivesTo evaluate the clinical characteristics and the long-term outcome of atrial fibrillation (AF) patients with dementia and history of syncope or falls. DesignObservational: analysis of a prospective registry. Setting and ParticipantsBetween 2012 and 2016, the Syncope and Dementia Registry enrolled patients in 12 geriatric departments. Follow-up evaluation was at 12 months. MeasuresClinical, functional, and cognitive assessment. ResultsOf the 522 patients (women, 62.1%; Mini-Mental State Examination 17 ± 6), 26.4% have or presented an AF history. Patients with AF were older (85 ± 6 vs 83 ± 6 years, P = .012), with higher heart rate (78 ± 17 vs. 73 ± 14 bpm, P < .001), prescribed drugs (6.9 ± 2.9 vs 5.9 ± 2.7, P < .001), and an increased number (3.9 ± 2.0 vs 3.0 ± 1.8, P < .001) and severity of comorbidities. Oral anticoagulant therapy was underprescribed (39.9%). Cardiac syncope was more frequently diagnosed (18.8 vs 4.9%, P < .001). At multivariate analysis, AF patients were characterized by advanced age, a higher severity of comorbidities, a greater number of prescribed drugs, an increased heart rate, and a more frequent presence of cardiac symptoms. One-year mortality differed little between patients with and without AF (27.7 vs 22.1%, P = .229). In the arrhythmia group, multivariate predictors of prognosis were disability (number of lost BADLs; P = .020) and a higher heart rate (P = .006). Conclusions and ImplicationsAF and postural stability-related issues often co-exist in persons with dementia. This complex of conditions is associated with an intricate clinical picture, underprescription of oral anticoagulants, and high long-term mortality. Future studies are needed to evaluate the effects of therapy optimization in this population.

Atrial fibrillation and frailty.

Both the prevalence of atrial fibrillation (AF) and frailty are increasing with age, and they often occur simultaneously, leading them to become the central concerns in this aging society. The incidence of frailty in patients with AF is highly variable, ranging from 4.4% to 75.4%, depending on different evaluating instruments used. Moreover, the incidence of frailty among patients with AF is on the rise, which indicated that patients with AF are more prone to frailty compared to patients without AF. The relationship between AF and frailty is complicated. Frailty elevates the risk of stroke and mortality in AF patients and is also associated with longer hospitalizations. On the other hand, it may reduce the appropriate anticoagulation in AF patients. However, the evidence of the effects of frailty on anti-arrhythmic and interventional therapy in patients with AF is scarce. Frailty affects both the management and the prognosis of AF in the geriatric population. Vice versa, AF could worsen the frail state and may represent a marker of frailty. However, there are still questions need to be resolved, for example, the impact of frailty on the interventional therapy of patients with AF. Therefore, the geriatric assessment of frailty should be considered when planning individualized management of AF in older patients.

Fibrosis independent atrial fibrillation in older patients is driven by substrate leukocyte infiltration: diagnostic and prognostic implications to patients undergoing cardiac surgery

BackgroundThe objectives of the study were to characterize and quantify cellular inflammation and structural remodeling of human atria and correlate findings with molecular markers of inflammation and patient surrogate outcome.MethodsVoluntary participants undergoing heart surgery were enrolled in the study and blood samples were collected prior to surgery, and right atrium samples were harvested intraoperatively. Blood samples were analyzed by flow cytometry and complete blood counts. Atrial samples were divided for fixed fibrosis analysis, homogenized for cytokine analysis and digested for single cell suspension flow cytometry.ResultsA total of 18 patients were enrolled and samples assessed. Isolated cells from the atria revealed a CD45+ population of ~ 20%, confirming a large number of leukocytes. Further characterization revealed this population as 57% lymphocytes and 26% monocyte/macrophages (MoΦ), with the majority of the latter cells being classical (CD14++/CD16−). Interstitial fibrosis was present in 87% of samples and correlated significantly with patient age. Older patients (> 65) had significantly more atrial fibrosis and cellular inflammation. AFib patients had no distinguishing feature of atrial fibrosis and had significantly greater CD45+ MoΦ, increased expression of MMP9 and presented with a significant correlation in length of stay to CCL-2/MCP-1 and NLR (neutrophil-to-lymphocyte ratio).ConclusionAtrial fibrosis is correlated with age and not determinate to AFib. However, severity of atrial leukocyte infiltration and markers of matrix degradation are determinant to AFib. This also correlated with CCL2 (or MCP-1) and NLR-indicative of marked inflammation. These data show the potential importance of diagnostic and prognostic assessments that could inform clinical decision making in regard to the intensity of AFib patient management.

Blood Pressure and Incident Atrial Fibrillation in Older Patients Initiating Hemodialysis.

We examined the association of predialysis systolic and diastolic BP and intradialytic hypotension with incident atrial fibrillation in older patients initiating hemodialysis. We used the US Renal Data System linked to the records of a large dialysis provider to identify patients aged ≥67 years initiating hemodialysis between January 2006 and October 2011. We examined quarterly average predialysis systolic BP, diastolic BP, and proportion of sessions with intradialytic hypotension (i.e., nadir systolic BP <90 mm Hg). We applied an extended Cox model to compute adjusted hazard ratios (HRs) of each exposure with incident atrial fibrillation. Among 17,003 patients, 3785 developed atrial fibrillation. When comparing predialysis systolic BP to a fixed reference of 140 mm Hg, lower predialysis systolic BP was associated with a higher hazard of atrial fibrillation, whereas higher systolic BP was associated with a lower hazard of atrial fibrillation. When comparing across a range of systolic BP for two hypothetical patients with similar measured covariates, the association varied by mean systolic BP: at systolic BP 190 mm Hg, each 10 mm Hg lower systolic BP was associated with lower atrial fibrillation hazard (HR, 0.94; 95% confidence interval, 0.90 to 1.00), whereas at systolic BP 140 mm Hg, a 10 mm Hg lower systolic BP was associated with a higher atrial fibrillation hazard (HR, 1.12; 95% confidence interval, 1.10 to 1.14). Lower diastolic BP was associated with higher atrial fibrillation hazards. Intradialytic hypotension was weakly associated with atrial fibrillation. In this observational study of older patients initiating hemodialysis, lower predialysis systolic BP and diastolic BP were associated with higher incidence of atrial fibrillation.

Abstract 207: VITAL-AF: A Pragmatic Trial Integrating Routine Screening for Atrial Fibrillation During Primary Care Visits

Background: Atrial fibrillation (AF) is a common age-related arrhythmia associated with increased risk of ischemic stroke. Novel technology may permit efficient and effective AF screening among undiagnosed, at-risk individuals to reduce ischemic stroke through use of guideline-indicated oral anticoagulants (OAC). We designed VITAL-AF (ClinicalTrials.gov NCT03515057) as a pragmatic cluster-randomized trial in a large primary care network in the United States, with the primary objective of assessing the benefit of population-based screening for AF in older patients using a single-lead ECG as part of routine care. Methods: VITAL-AF was designed to be generalizable, implementable, and pragmatic. VITAL-AF includes all patients ≥ 65 years of age attending an outpatient visit in a participating site with a physician or nurse practitioner, embeds screening as part of routine assessment of vital signs at each encounter, utilizes clinic medical assistants rather than research personnel to conduct screening, and assesses outcomes using electronic health record data. Practices were randomized to the screening intervention or control arm. Control practices continue with true usual care that may include pulse palpation and rhythm assessment based upon physician standard practice. Here we present historical data from the network about the size, visit patterns, and characteristics of the eligible population prior to trial enrollment starting July 31, 2018. Results: Overall, 142,291 patients were seen in network practices in the prior 3 years. There were 35,856 (25%) eligible patients ≥ 65 years of age seen in 16 participating study sites (hospital, community and health center clinics) including 4,704 (13%) patients with known AF. In 2017, 93% of eligible patients ≥ 65 years completed at least one primary care outpatient visit, with 67% completing multiple visits. This population has many risk factors for AF including: 41% ≥ 75 years of age, 43% male, 70% with hypertension, 19% with coronary artery disease, 18% with diabetes, and 8% with heart failure. Among those without prevalent AF on OAC, 93% had a CHA2DS2-VASc score ≥ 2 with 40% having a score ≥ 4. The trial is in progress and subject accrual is expected to be complete as of late fall 2019. Conclusion: VITAL-AF is a pragmatic, population-based trial of a screening program for undiagnosed AF in older at-risk patients within a primary care network. To emphasize generalizability, ease of implementation, and to facilitate screening uptake across a range of primary care clinics, VITAL-AF uses a single, age-based eligibility criterion. A small percentage of patients with low CHA2DS2-VASc score or with prevalent AF will be screened. Outcome assessment will evaluate rates of new AF detection and appropriate use of OACs among all patients ≥ 65 years of age seen in a participating clinic.

Predialysis Nephrology Care and Incident Atrial Fibrillation in Older Patients With ESKD Initiating Dialysis

Atrial fibrillation (AF) is common in patients with end-stage kidney disease (ESKD) on dialysis. Whether pre-ESKD nephrology care associates with AF is uncertain. We conducted a retrospective cohort study of older US patients (≥67 years) with Medicare A&B who initiated dialysis (1996-2013) without a prior diagnosis of AF. Patients were categorized by the duration and number of predialysis nephrology outpatient visits. Patients were followed for 1 year for a new diagnosis of AF. We used multivariable Cox proportional hazards regression while accounting for the competing risks of kidney transplantation and death. We identified 316,067 patients with ESKD initiating dialysis between 1996 and 2013 who had no prior AF diagnosis. In this cohort, 66.9% had any pre-ESKD outpatient nephrology care, with the first outpatient nephrology visit before dialysis initiation occurring at≤6 months in 17.9%, 7 to 12 months in 9.4%, and >12 months in 39.6%. Outpatient pre-ESKD nephrology care for≤6, 7 to 12, and >12 months versus none yielded adjusted cause-specific hazard ratios (HRs) of 0.87 (95% CI: 0.84-0.89), 0.83 (95% CI: 0.81-0.86), and 0.85 (95% CI: 0.83-0.87) for incident AF, respectively. Further, having 1 to 4 pre-ESKD outpatient nephrology visits, 5 to 9 visits, and≥10 visits versus none yielded adjusted cause-specific HRs of 0.89 (95% CI: 0.86-0.91), 0.86 (95% CI: 0.83-0.88), and 0.81 (95% CI: 0.79-0.83), respectively. Having any predialysis nephrology care before initiation of dialysis was associated with slightly lower adjusted rates of incident AF over the first year of dialysis. The optimal timing and intensity of nephrology care to reduce the incidence of AF and other adverse health events requires further study.