Elderly Atrial Fibrillation Patients Research Articles

Clinical Factors Associated with a Successful Catheter Ablation Outcome in Elderly Patients with Atrial Fibrillation.

Catheter ablation is currently an established treatment for symptomatic paroxysmal atrial fibrillation (AF). We focused on elderly patients with a high prevalence of AF and attempted to identify the clinical factors associated with unsuccessful ablation outcomes.Among 735 consecutive patients who underwent AF ablation procedures, 108 (14.7%, 66 men) aged ≥ 75 years were included. Of them, 80 had paroxysmal AF, and the remaining 28 non-paroxysmal AF. All patients underwent pulmonary vein (PV) isolation and occasionally additional ablation. When AF recurred, redo ablation procedures were performed if the patient so desired.The mean number of ablation procedures was 1.1 ± 0.4 times per patient. During a mean follow-up of 38.7 ± 21.7 months, sinus rhythm was maintained in 100 patients (92.6%) without any antiarrhythmic drugs, but not in the remaining 8 (7.4%). Left atrial diameter (LAD, P < 0.001), left ventricular (LV) systolic diameter (P < 0.001), LV diastolic diameter (P = 0.001), non-PV AF foci (P = 0.036), and diabetes (P = 0.045) were associated with unsuccessful ablation procedures. Multivariate logistic regression analysis revealed a large LAD and non-PV AF foci were significant independent predictors of AF recurrences, with odds ratios of 0.76 (P = 0.019) and 0.04 (P = 0.023), respectively. In a total of 124 procedures, one major (0.8%) and 11 minor (8.9%) complications occurred.In elderly AF patients, catheter ablation of AF is effective and safe. Non-PV AF foci and a large LAD were independent clinical predictors of unsuccessful AF ablation outcomes.

Stroke prevention in elderly patients with non-valvular atrial fibrillation in the BALKAN-AF survey.

Atrial fibrillation (AF) is common amongst the elderly, but this group tends to be suboptimally treated. Limited data are available on the stroke prevention strategies in the elderly, especially in the Balkan region. We investigated the use of oral anticoagulant therapy (OAC) amongst elderly AF patients in clinical practice in the Balkan region. A 12-week prospective snapshot survey (2014-2015) of consecutive non-valvular AF patients was conducted in Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Montenegro, Romania and Serbia. Data were collected via an electronic case report form. Of 2671 patients, 418 (15.6%) were ≥80years old. Overall, OAC was used in 1965 patients (73.6%). Compared with younger patients, the elderly (age≥80) had a higher mean CHA2 DS2 -VASc score (3.22±1.71 vs 4.89±1.35, P<.001) and more often a HAS-BLED score of ≥3 (n=198 [47.0%] vs n=625 [27.3%], P<.001), but were less likely to receive OAC (n=269 [64.4%] vs n=1696 [75.3%], odds ratio [OR] 0.91; 95%CI 0.86-0.97, P=.003). There was no significant association between OAC use and mean CHA2 DS2 -VASc (OR 0.86; 95%CI 0.75-1.00, P=.053) or HAS-BLED score (OR 1.21; 95%CI 0.81-1.81, P=.349) in the elderly. In the BALKAN-AF Survey, elderly AF patients were less likely to receive the guideline-adherent treatment despite their less favourable risk profile. Since OAC nonuse among the elderly was not associated with increased HAS-BLED score, factors other than patients' risk profile could influence the implementation of guideline-adherent treatment for thromboprophylaxis in the elderly AF patients.

Age-Related Differences in the Clinical Characteristics and Treatment of Elderly Patients With Atrial Fibrillation in Japan - Insight From the ANAFIE (All Nippon AF In Elderly) Registry.

Atrial fibrillation (AF) is increasing as the global population ages. Elderly AF patients (≥75 years) have a worse prognosis than younger patients, and effective management is often difficult due to multiple comorbidities. This analysis examined the age-related differences in clinical characteristics and treatment in real-world elderly Japanese AF patients.Methods and Results:The ANAFIE Registry is a multicenter, prospective, observational registry of 32,726 non-valvular AF patients aged ≥75 years. The present study assessed the age-related differences in baseline clinical status and anticoagulant therapy between age groups 75-<80, 80-<85, 85-<90, and ≥90 years. The prevalence of persistent or permanent AF increased, and that of paroxysmal AF decreased, with increasing age (trend P<0.0001). The risk of stroke, based on CHADS2and CHA2DS2-VASc scores, and bleeding, based on HAS-BLED score, increased with age. Both warfarin and apixaban were used more often as age increased (trend P<0.0001, for each), while other anticoagulants were used less. Anticoagulant doses were significantly lower in older patients. Permanent/persistent AF, comorbidities, and cardiovascular and bleeding risk all increased significantly with age. Furthermore, use of warfarin and apixaban increased with age, accompanied by a decrease in other oral anticoagulant usage.

Plasma D-Dimer Level as a Subclinical Marker of Thrombotic Risk in Elderly Patients with Atrial Fibrillation

Aged patients with atrial fibrillation (AF) are at high risk of both thromboembolic and hemorrhagic complications of the disease and its treatment. A study was conducted to assess the role of the D-dimer plasma level as a marker of thrombosis in aged patients with AF having no clinical signs of active thrombosis with respect to the used treatment strategy and the quantitative thrombotic and hemorrhagic risk of AF. The results show that the D-dimer plasma levels correlate with the scores of thromboembolic and hemorrhagic risks in groups on antiplatelet agents but not anticoagulants, with the difference in D-dimer level driven by a subgroup on CHA2DS2-VASc point ≥5. A high D-dimer level was associated with in-hospital mortality and AF rhythm at the moment of blood sample collection. Therefore, the accuracy of risk prognosis for fatal complications of AF in elderly patients may be increased with the use of the laboratory markers of thrombus formation such as the D-dimer level and with the use of the obtained results as a guide to antithrombotic therapy.

Is dual therapy the correct strategy in frail elderly patients with atrial fibrillation and acute coronary syndrome?

Atrial fibrillation (AF) is a very common arrhythmia in clinical practice. Its incidence and prevalence are age-related and are growing in the last years. Age is a risk factor also for coronary artery disease (CAD), and with the evolution of preventive care, the first event (acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI)) takes place at a later age. If elderly patients with AF and CAD undergo ACS or PCI, they have indication to assume triple therapy. Triple therapy (oral anticoagulation (OAC) plus dual antiplatelet therapy (DAPT)) exposes patients to high bleeding risk. In the last 10 years, several clinical trials have tested dual therapy (OAC plus single antiplatelet therapy) in AF patients who undergo ACS or elective PCI. WOEST trial has tested warfarin + clopidogrel against triple therapy. PIONEER AF-PCI trial has tested low-dose rivaroxaban + P2Y12 inhibitor or very low-dose rivaroxaban + DAPT against standard triple therapy with warfarin. RE-DUAL PCI trial has tested two doses of dabigatran + P2Y12 inhibitor against standard triple therapy with Warfarin. AUGUSTUS trial has tested apixaban against warfarin both in dual therapy with P2Y12 inhibitor and in triple therapy with a P2Y12 inhibitor and aspirin. ENTRUST-AF PCI, last published study, has tested edoxaban + P2Y12 inhibitor against triple therapy. All these trials show dual therapy reduces significantly bleeding risk than triple therapy. In this paper, we analyze these clinical trials to understand if dual therapy results can be applied to elderly patients and what is probably the better approach in elderly AF patients undergo to ACS or PCI.

Costs and long-term outcomes following pulmonary vein isolation for atrial fibrillation in elderly patients using second-generation cryoballoon vs. open-irrigated radiofrequency in China

PurposeLimited comparative data are available regarding catheter ablation (CA) of atrial fibrillation (AF) using second-generation cryoballoon (CB-2) vs. radiofrequency (RF) ablation in elderly patients (> 75 years old). The present study aimed to compare the costs and clinical outcomes in elderly patients using these two strategies.MethodsElderly patients with symptomatic drug-refractory paroxysmal/short-lasting persistent AF were included in the study. Pulmonary vein isolation (PVI) was performed in all patients.ResultsA total of 324 elderly patients were included (RF,176; CB-2,148) from September 2016 to April 2019. The CB-2 was associated with shorter procedure time and left atrial dwell time (112.9 ± 11.1 vs. 135.1 ± 9.9 min, P < 0.001; 53.7 ± 8.9 vs. 65.1.9 ± 9.0 min, P < 0.001) but marked fluoroscopy utilization (22.1 ± 3.3 vs. 18.5 ± 3.6 min, P < 0.001). Complications occurred in 3.3% (CB-2) and 6.2% (RF) of patients with no significant different (p = 0.307). The length of stay after ablation was shorter, but the costs were higher in the CB-2 group (1.94 vs. 2.53 days, P < 0.001 and 91,132.6 ± 3723.5 vs. 81,149.4 ± 6824.1 CNY, P < 0.001) compared to the RF group. Additionally, the rate of early recurrence of atrial arrhythmia (ERAA) was lower in the CB-2 group (14.2 vs. 23.3%, P = 0.047), but the long-term success rate was similar between two groups.ConclusionsCB-2 is associated with shorter procedure time, left atrial dwell time, and length of stay after ablation, as well as lower ERAA, but its costs and fluoroscopy time are greater than the RF group. Moreover, the rate of complications and long-term success is similar between the two groups.

Abstract 249: The Costs and Acute Outcomes Following Pulmonary Vein Isolation for Atrial Fibrillation in Elderly Patients a Comparison Between Cryoballoon and Radiofrequency Ablation

Backgroup: Limited comparative data exist regarding catheter ablation (CA) of atrial fibrillation (AF) using second-generation cryoballoon (CB-2) ablation versus radiofrequency (RF) ablation in elderly patients (&gt;75 years ). This study aims to compare the costs and periprocedural outcomes in elderly patients using these two strategies. Methods: Elderly patients (&gt;75years) with symptomatic drug-refractory AF were included in the study. Pulmonary vein isolation (PVI) was performed in all patients by CB or RF. The costs and periprocedural outcomes of the two strategies are compared using SPSS 22. Results: 324 elderly patients with symptomatic drug-refractory paroxysmal/short-lasting persistent AF received PVI using RF (n=176) and CB-2 (n=148) from September 2016 to April 2019. The CB-2 was associated with shorter procedure duration and left atrial dwell time (128.9±18.3 vs. 152.8±18.9 minutes, P&lt;0.001; 89.4±18.4 vs. 101.9± 22.2minutes, P &lt;0.001), but greater fluoroscopy utilization (24.3±10.9 vs. 19.2±7.5 minutes, P &lt;0.001). Periprocedural complications occurred in 3.4% (CB-2) and 9.1% (RF) of patients (P=0.037). There was no significant difference between 2 groups for AF/atrial tachycardia (AT) recurrence until discharge (16.2 vs. 18.7%, P = 0.552). The length of stay after ablation was shorter, but the costs were greater in the CB-2 group ( P &lt;0.001). Conclusions: Both CB-2 and RF ablation appear to be safe and effective for AF in elderly patients (&gt;75 years). In addition, CB-2 is associated with shorter procedure time, left atrial dwell time, and length of stay after ablation, as well as lower complication rates, but its costs and fluoroscopy time are greater than those of the RF group.

Etiology of Minor Troponin Elevations in Patients with Atrial Fibrillation at Emergency Department-Tropo-AF Study.

Patients with atrial fibrillation (AF) presenting to the emergency department (ED) often have elevated cardiac troponin T (TnT) levels without evidence of type 1 myocardial infarction. We sought to explore the causes and significance of minor TnT elevations in patients with AF at the ED. All patients with AF admitted to the ED of Turku University Hospital between 1 March, 2013 and 11 April, 2016, and at least two TnT measurements, were screened. Overall, 2911 patients with a maximum TnT of 100 ng/L during hospitalization were analyzed. TnT was between 15 and 100 ng/L in 2116 patients. The most common primary discharge diagnoses in this group were AF (18.1%), infection (18.3%), ischemic stroke/transient ischemic attack (10.7%), and heart failure (5.0%). Acute coronary syndrome (ACS) was equally uncommon both in patients with normal TnT and elevated TnT (4.4% vs. 4.5%). Age ≥75 years, low estimated glomerular filtration rate (eGFR), high C-reactive protein (CRP), and hemoglobin <10.0 g/dL, were the most important predictors of elevated TnT. Importantly, TnT elevation was a very frequent (>93%) finding in elderly (≥75 years) AF patients with either low eGFR or high CRP. In conclusion, minor TnT elevations carry limited diagnostic value in elderly AF patients with comorbidities.

Correlation between frailty status and anticoagulation therapy in elderly patients with atrial fibrillation

Objective To investigate the correlation between frailty status and anticoagulation therapy in elderly patients with atrial fibrillation. Methods A total of 131 atrial fibrillation inpatients in our hospital aged 70 years and over with a mean age of(77.4±6.4)years were enrolled from January 2017 to June 2018 in this retrospective study.According to the state of anticoagulation therapy at discharge, patients were divided into the anticoagulation group(n=67)and the non-anticoagulation group(n=64). Data including gender, age, N-terminal pro-brain natriuretic peptide(NT-proBNP), glomerular filtration rate(eGFR), the type of medication, HAS-BLED(Hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly), CHA2DS2-VASc scores, Charlson comorbidity index and clinical frailty scores(CFS)were recorded and compared between the two groups.Spearman correlation was used to analyze the correlation between frailty degrees and program of anticoagulant therapy.Two-class Logistic regression models were used to analyze the related factors for programs of anticoagulant therapy. Results The incidence of the frailty syndrome was 56.49% in 131 elderly patients with atrial fibrillation.Compared with the anticoagulation group, non-anticoagulation group showed that the CFS score[(5.73±1.85)vs.(3.69±2.07), P 0.05). The correlation analysis showed that there was a negative correlation between the application of anticoagulants and CFS grade in elderly patients with atrial fibrillation(r=-0.138, P<0.05). Multivariate Logistic regression analysis showed that age, CFS score and the incidence of frailty state were risk factors in elderly atrial fibrillation patients without the anticoagulant therapy(P<0.05). Conclusions The incidence of frailty state in elderly patients with atrial fibrillation is high, and the proportion of patients receiving the anticoagulant therapy is low.Age and frailty may be the most important influencing factors for anticoagulant therapy.Therefore, it is of great significance to incorporate frailty assessment into the management of anticoagulant therapy in elderly patients with atrial fibrillation. Key words: Frailty; Atrial fibrillation; Anticoagulation

Healthcare resource utilization and expenditures among newly-diagnosed elderly non-valvular atrial fibrillation patients initiating oral anticoagulants

Aims: Non-valvular atrial fibrillation (NVAF) prevalence increases with age. Hence, evaluating the economic burden among older-aged patients is vital. This study aimed to compare healthcare resource utilization (HRU) and costs among newly-diagnosed older-aged NVAF patients treated with warfarin, rivaroxaban, or apixaban vs. dabigatran.Materials and Methods: Newly-diagnosed older-aged (aged ≥65 years) NVAF patients initiating dabigatran, warfarin, rivaroxaban, or apixaban (first prescription date = index date) from 01JAN2010-31DEC2015 and with continuous enrollment for ≥12 months pre-index date were included from 100% Medicare database. Patient data were assessed until drug discontinuation/switch/dose change/death/disenrollment/study end (up to 12 months). Dabigatran initiators were 1:1 propensity score-matched (PSM) with warfarin, rivaroxaban, or apixaban initiators. Generalized linear models were used to compare all-cause HRU and costs per-patient-per-month (PPPM) between the matched cohorts.Results: After PSM with dabigatran, 70,531 warfarin, 51,673 rivaroxaban, and 25,209 apixaban patients were identified. Dabigatran patients had significantly fewer generalized-linear-model-adjusted PPPM hospitalizations (0.114 vs. 0.123; 0.111 vs. 0.121), and outpatient visits (2.864 vs. 4.201; 2.839 vs. 2.949) than warfarin and rivaroxaban patients, respectively, but had significantly more PPPM hospitalizations (0.103 vs. 0.090) and outpatient visits (2.780 vs. 2.673) than apixaban patients (all p < .0001). Dabigatran patients incurred significantly lower adjusted total PPPM costs ($3,309 vs. $3,362; $3,285 vs. $3,474) than warfarin and rivaroxaban patients, respectively (all p < .01) but higher total PPPM costs ($3,192 vs. $2,986) than apixaban patients (all p < .0001).Limitations: This study is subject to the inherent limitations of any claims dataset, including potential bias from coding errors and identification of medical conditions using diagnosis codes as opposed to clinical evidence. Medications filled over-the-counter or provided as samples by the physician are never captured in claims data.Conclusions: Newly-diagnosed older-aged NVAF patients initiating dabigatran incurred significantly lower adjusted all-cause HRU and costs than warfarin and rivaroxaban patients but higher adjusted HRU and costs than apixaban patients.

66Clinical outcomes after catheter ablation for atrial fibrillation in elderly patients: a French nationwide cohort study

Abstract Catheter ablation for atrial fibrillation (AF) is a validated therapy for patients with symptomatic AF to prevent recurrences. The CASTLE AF trial indicated that ablation for AF in patients with heart failure was associated with a lower rate of death from any cause or hospitalization for worsening heart failure than was medical therapy. However, the benefit of AF ablation was not significant in older patients (&gt;65 yo). The purpose of our study was to compare the incidence of these events in patients after AF catheter ablation versus patients not treated with AF ablation at a nationwide level and to analyse whether the possible benefit with AF ablation may differ among patients younger or older than 75 yo. Methods This French longitudinal cohort study was based on the national hospitalization PMSI (Programme de Médicalisation des Systèmes d'Information) database covering hospital care from the entire population. We included all patients, over 18 years old, with AF from January 2010 to December 2015. Results Among the 1,663,284 patients identified with AF, 28,018 patients were treated with AF ablation (28% female, mean age 60±10 yo) and 1,635,266 did not have AF ablation (48% female, mean age 78±11 yo). Among those treated with AF ablation, 1,605/28,018 patients (5.7%) were aged &gt;75 yo. During follow-up (456±546 days), hospitalization with a primary diagnosis of HF and death were recorded. Incidences of hospitalization for HF and death were significantly lower in AF ablation group (respectively 6.09% vs 13.29% person per year, p&lt;0.0001, and 1.49% vs 17.11% person per year, p&lt;0.0001). These associations were confirmed in a multivariable analysis after adjustment on age and other comorbidities (HR 0.66, 95% CI 0.63–0.69, p&lt;0.0001 for HF and HR 0.21, 95% CI 0.19–0.23, p&lt;0.0001 for all-cause death). Results were significant and relatively similar whether patients were aged below or above 75 yo: HR 0.63, 95% CI 0.60–0.66, p&lt;0.0001 when age &lt;75 yo and HR 0.60, 95% CI 0.51–0.70, p&lt;0.0001 when age &gt;75 yo for hospitalization for HF; HR 0.21, 95% CI 0.19–0.24, p&lt;0.0001 when age &lt;75 yo and HR 0.36, 95% CI 0.29–0.45, p&lt;0.0001 when age &gt;75 yo for all-cause death. Conclusion In the nationwide analysis of unselected AF patients seen in hospitals, AF ablation was independently associated with a lower risk of hospitalization for HF and death whether patients were aged below or above 75 yo.

P3612Validation of Charlson Comorbidity Index to predict adverse events in elderly patients with Atrial Fibrillation and Acute Coronary Syndrome: an analysis from LONGEVO-SCA Registry

Abstract Background Aging is frequently characterized by the coexistence of several comorbid conditions that increase the adverse prognosis during hospitalization. There are few scores to analyze the impact of comorbidities in prognosis. Charlson Comorbidity Index (CCI). This score evaluates the burden of comorbidity in general population but the influence within cardiac diseases is unknown. Purpose The aim of this study was to analyze the relationship of CCI in adverse outcomes at short-term follow-up in elderly patients with atrial fibrillation (AF) admitted after an acute coronary syndrome (ACS). Methods The prospective multicenter LONGEVO-SCA included unselected elderly patients hospitalized after non-STACS. In this substudy, we analyze the influence of comorbidities in elderly AF patients, comparing high quartiles of CCI (Q3-Q4: high burden of comorbidities) to low quartiles (Q1-Q2) and the predictive performance of adverse events at 6 months follow-up of CCI. Results We analyzed 531 patients (mean age 84.4±3.6 years; 322 (60.6%) male). 128 (24.1%) had AF diagnosis. 91 (71.1%) patients were classified into Q1-Q2 and 37 (28.9%) patients into Q3-Q4. We analyzed the association of clinical factors and adverse events and, after Cox multivariate regression analysis, CCI was independently associated with readmissions [HR 1.19, 95% CI (1.02–1.39); p=0.020) and all-cause mortality [HR 1.32, 95% CI (1.09–1.59); p=0.003]. Patients into Q3-Q4 had higher risk of mortality than patients into Q1-Q2 [HR 5.52, 95% CI (1.01–30.3); p=0.049]. Kaplan Meier analysis showed that AF patients into Q3-Q4 had significantly worse prognosis during the follow-up with high risk of all-cause mortality (p=0.034) and readmissions due to ACS (p=0.027). We observed good predictive performance of CCI for mortality (c-statistic 0.705; p&lt;0.001) and modest predictive performance for readmissions (c-statistic 0.627; p&lt;0.001). Event Free Survival according Charlson Conclusions Patients into high quartiles of CCI had higher risk of adverse events during the follow-up. CCI was an independent predictor of all-cause mortality and readmissions in elderly patients. Indeed, this is the first time to validate CCI to predict adverse events in AF patients with ACS.

Physical, cognitive, and psychosocial conditions in relation to anticoagulation satisfaction among elderly adults with atrial fibrillation: The SAGE-AF study.

Successful anticoagulation is critical for stroke prevention in adults with atrial fibrillation (AF). Anticoagulation satisfaction is a key indicator of treatment success. While physical, cognitive, and psychosocial limitations are common in elderly AF patients, their associations with anticoagulation satisfaction are unknown. Examine whether anticoagulation satisfaction differs among AF patients with and without physical, cognitive, and psychosocial conditions. The study comprised AF patients greater than or equal to 65 years old who were prescribed an oral anticoagulant (warfarin 57%; direct oral anticoagulant [DOAC] 43%). Frailty, cognitive function, social support, depressive symptoms, vision, hearing, and anxiety were assessed using validated measures. Anticoagulation satisfaction was measured using the anticlot treatment scale. Participants (n = 1037, 50% female) were on average 76 years old. The following conditions were prevalent: frailty (14%), cognitive impairment (42%), social isolation (13%), vision impairment (35%), hearing impairment (36%), depression (29%), and anxiety (24%). Average anticlot treatment burden scale was 55 out of 60 (lower burden scales indicating higher perceived burden). Patients with high perceived burden were older, more likely to be female, and receive warfarin. After adjusting for confounders, visual impairment (adjusted odds ratio [95% confidence interval]: 1.7 [1.2-2.4]), depressive symptoms (2.4 [1.6-3.7]), and anxiety (1.8 [1.2-2.7]) were significantly associated with high perceived burden. Different conditions were associated with high perceived burden in warfarin vs DOAC users. Physical, cognitive, and psychosocial limitations are prevalent and associated with high perceived anticoagulation burden among elderly AF adults. These conditions merit consideration in anticoagulation prescribing.

A Cluster Analysis of the Japanese Multicenter Outpatient Registry of Patients With Atrial Fibrillation

Recently, cluster analysis was used to identify unique clinically relevant phenotypes of atrial fibrillation (AF) in a cohort from the United States (US) and classified clusters according to the presence of comorbid behavioral disorders, those with conduction disorders, or atherosclerotic comorbidities. Whether these phenotypes are consistent in AF cohorts outside the US remains unknown. Thus, we sought to conduct a cluster analysis in a cohort of Japanese AF patients. We conducted a cluster analysis of phenotypic data (46 variables) in an AF patient cohort recruited from 11 Japanese sites participating in the KiCS-AF Registry. Overall, 2,458 AF patients (median [IQR] age, 68.0 [60.0 to 76.0]; 30.3% female; median [IQR] CHA2DS2-Vasc, 2 [1, 3]) were analyzed. Similar to the US cohort, atherosclerotic comorbidities were identified as distinguishing factors to characterize clusters. Distribution of AF type and left atrial (LA) size substantially varied and was the key feature for cluster formation. CHA2DS2-Vasc score also contributed to cluster formation, although behavioral disorders and/or conduction disorders did not readily characterize clusters. Subsequently, the cohort was classified into 3 clusters: (1) Younger paroxysmal AF (n = 1,190); (2) Persistent/permanent AF with LA enlargement (n = 1,143); and (3) Atherosclerotic comorbid AF in elderly patients (N = 125). In conclusion, conventional classifications, such as atherosclerotic risk factors and CHA2DS2-Vasc score contributed to cluster formation in mutually, whereas in nonatherosclerotic clusters, AF type or LA size rather than the presence or absence of behavior risk factors or sinus node dysfunction (tachy-brady syndrome) seemed to contribute to cluster formation in the Japanese cohort.

Determinants of Antithrombotic Treatment for Atrial Fibrillation in Octogenarians: Results of the OCTOFA Study.

Atrial fibrillation, the most frequent form of arrhythmia, affects 5-15% individuals aged > 80 years. Stroke is a major risk for atrial fibrillation patients. The benefits of anticoagulant therapy clearly outweigh the risk of hemorrhage, even in the elderly. Despite the efficacy of warfarin, many eligible patients receive no prophylactic antithrombotic therapy. New generation oral anticoagulants compare favorably with vitamin K antagonists in the prevention of thromboembolic events and hemorrhage. These new agents are likely to influence the prescribing habits of anticoagulants in atrial fibrillation. The aim of this study to investigate both the frequency and the determining factors of anticoagulant prescriptions in AF patients aged≥80years and followed upby private-practice cardiologists in France. The OCTOFA (Atrial Fibrillation in Octogenarians) Study assessed the anticoagulant prescribing habits of cardiologists in France. The volunteer cardiologistsrecruited all consecutive patients fulilling the inclusion criteria. Between June 2013 and September 2016, 89 cardiologists recruited 738 eligible patients: age ≥80 years, non-valvular atrial fibrillation, no other compelling indication for anticoagulation therapy, no recent acute coronary syndrome or stroke. Most (90.7%) patients were on oral anticoagulant therapy: vitamin K antagonist or non-vitamin K antagonist oral anticoagulants, low molecular weight heparin (1.4%), aspirin (5.7%), and no antithrombotic treatment (2.2%). Patients on vitamin K antagonists were older (p<0.001), had lower renal function (p=0.033), and had a more frequent history of myocardial infarction (p<0.001), heart failure (p=0.001), peripheral artery disease (p=0.033), major hemorrhage (p=0.025), and falls (p=0.045). Four determining factors of anticoagulant prescriptions were statistically significant: high CHA2DS2-VASc score (p<0.001), high HAS-BLED score (p<0.001), age >90 years (p=0.001), and moderate/severe cognitive impairment (p=0.002). Most private-practice cardiologists prescribe anticoagulant treatment according to current guidelines in elderly atrial fibrillation patients. Non-vitamin K antagonist oral anticoagulants represent a significant proportion of prescriptions.

Abstract TP526: Can Electronic Alerts Improve Oral Anticoagulant Use in Elderly Atrial Fibrillation Patients?

Background: Oral anticoagulant (OAC) for atrial fibrillation use remains underutilized despite evidence in favor of its utility. In a three-center study examining the efficacy of a technological intervention to improve OAC use, two sites were randomly selected to incorporate an embedded alert in the electronic health record (EHR) while the third site provided usual care. At the intervention sites, the EHR calculated each patient’s CHA 2 DS 2 -VASc score and alerted the clinician when OAC therapy was recommended. We aimed to investigate whether this system increased OAC use in elderly patients. Methods: Patient medication was tracked at the time of hospitalization, discharge, and within 30 days of discharge. Patients were categorized by age and study arm to assess medication use at last known follow-up via the Chi Square and Fisher’s Exact tests. Results: The control site contained 152 patients, 65 being 75+ years of age, while the two intervention sites contained 164 patients, also with 65 patients who were 75+ years of age. Those aged 75+ show statistically significant proclivity for prior strokes (&lt;0.001), coronary artery disease (0.04), hypertension (0.004), and lower rate of diagnosed obstructive sleep apnea (0.001). Furthermore, they tend to be females (53.9%). The median CHA 2 DS 2 -VASC score was 4 in the elderly group and 2 in the younger group (p&lt;0.001). Use of warfarin or OACs in these two populations did not vary at baseline. At follow-up, use of warfarin was statistically significantly higher in those 75+ (21.9% vs 12.8%, p-value=0.04) but not when partitioned by study arm or when all OAC use was considered. There was no difference in OAC use between the intervention and control sites (43% vs. 54% p=0.22). Conclusions: Despite increased CHA 2 DS 2 -VASc scores, we did not demonstrate the benefit of electronic alerts among elderly AF patients. Additional research is needed regarding methods to overcome therapeutic inertia in this area. Study support: Boehringer-Ingelheim

Abstract WP522: Catheter Ablation of Atrial Fibrillation and Long-Term Cardiovascular Outcomes

Introduction: Catheter ablation is increasingly used in older patients with atrial fibrillation (AF) but the long-term effects on vascular outcomes in this population remain unclear. Methods: We used inpatient and outpatient claims between 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. Patients ≥66 years old who underwent AF ablation and control AF patients were matched in a 1:1 ratio based on a propensity score calculated from their age, sex, race, a socioeconomic status score, visit date, date of first AF diagnosis, history of vascular events, CHA 2 DS 2 -VASc score, and Charlson comorbidity index. Outcomes were ischemic stroke, myocardial infarction, heart failure hospitalization, major bleeding, number of AF hospitalizations, and all-cause mortality. Variables were ascertained using previously validated code algorithms. Survival statistics, Cox proportional hazards analysis, and Poisson regression were used to compare groups with adjustment for warfarin use during follow-up. Results: The 2,119 patients who underwent ablation and 2,119 controls were well matched, including on age (72.8 ±5.6 years), sex (39.5% female), race (92.5% white), CHA 2 DS 2 -VASc score (4.4 ±1.5), Charlson comorbidities (2.4 ±2.0), and duration since AF diagnosis (1.2 ±1.4 years). During 2.8 (±1.9) years of follow-up, ablation was associated with a lower risk of death (5.9% vs 10.8% per year) (HR, 0.55; 95% CI, 0.48-0.63) or heart failure hospitalization (5.9% vs 10.7% per year) (HR, 0.57; 95% CI, 0.47-0.70) and fewer AF hospitalizations (incidence rate ratio, 0.85; 95% CI, 0.81-0.89). There was no difference in the risk of ischemic stroke (0.9% vs 1.2% per year) (HR, 0.77; 95% CI, 0.54-1.12), myocardial infarction (0.8% vs 1.0% per year) (HR, 0.75; 95% CI, 0.50-1.11), or major bleeding (3.0% vs 3.4% per year) (HR, 0.90; 95% CI, 0.72-1.11). Conclusions: In a propensity-matched cohort of elderly AF patients, catheter AF ablation was associated with lower mortality and fewer hospitalizations for AF or heart failure, but ablation was not associated with a long-term reduction in thromboembolic or bleeding events.

Atrial fibrillation in elderly patients with implantable loop recorders for unexplained syncope.

An implantable loop recorder (ILR) assists in the diagnosis of unexplained syncope and atrial fibrillation (AF). Both become prevalent with age. Limited data exist describing the incidence of AF as the diagnostic rhythm underlying syncope in the elderly. This study aims to report the incidence of AF in older adults with ILRs for unexplained syncope and identify clinical characteristics associated with AF in this population. Retrospective observational study on patients with unexplained syncope seen in syncope clinics from two Canadian centers. Participants were ≥65years old, without a history of AF, and received an ILR for unexplained syncope. Data were collected from patient's clinic charts. Arrhythmia diagnosis was based on ILR electrocardiogram reading during syncope (symptom-rhythm correlation). Fisher's exact test and the Student's t test were used to compare participants with and without AF. In our cohort of 222 patients, 124 were females and 98 were males. Mean age at implant was 80±8years. Arrhythmia was diagnosed in 98 patients (44.1%). Median time to diagnosis was 18months. AF was diagnosed in 17 (7.7%) participants. There were fewer males in the AF group than the no AF group (11.8%, 46.8%, p=0.01). Age, baseline EKG, and prevalence of hypertension, diabetes, stroke, or ischemic heart disease were not statistically different between patients with AF and without AF. Atrial fibrillation was a common diagnostic rhythm in this cohort of adults, aged 65 and older, with ILRs for unexplained syncope. It was observed more frequently in females.

Propensity-matched comparison of cryoballoon and radiofrequency ablation for atrial fibrillation in elderly patients

Pulmonary vein isolation (PVI) with a cryoballoon (CB) is an effective treatment for atrial fibrillation (AF). The efficacy of CB PVI for elderly patients with AF remains unclear. We aimed to analyze the clinical outcomes of CB ablation compared with radiofrequency (RF) ablation in elderly patients with AF. This was a single-center retrospective study of 305 patients older than 75 years with paroxysmal and persistent AF who underwent PVI between January 2012 and August 2017. Patients were matched according to propensity scores in a logistic regression model. The end point of this study was AF/atrial tachycardia recurrence at 12-month follow-up. In total, 198 patients (99 matched pairs) were analyzed. The ratio of paroxysmal AF was 83%, and the mean age was 78 ± 2 years. The mean procedure time was significantly lower in the CB group (134 ± 62 minutes vs 190 ± 51 minutes; P < .001). There was no significant difference between the groups in terms of success rate at 12 months after the procedure (CB 80.5% vs RF 79.4%; P = .72) or incidence of complications (CB 12% vs RF 16%; P = .80). Kaplan-Meier estimates revealed no significant difference between clinical outcomes after PVI with a CB or RF for elderly patients with non-pulmonary vein foci that were all successfully ablated (CB 68.8% vs RF 68.4% at 12 months; P = .835). The efficacy of PVI with a CB might be comparable to that of PVI with RF in AF patients older than 75 years and involve a shorter procedure time.

Genetic polymorphisms of matrix metalloproteinase-9, tissue inhibitor of matrix metalloproteinase-1 and development of postoperative atrial fibrillation in elderly patients

Aim . The aim of the study was to assess the association of genetic polymorphisms of matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) with atrial fibrillation development in elderly patients with coronary artery disease (CAD), undergoing coronary artery bypass graft (CABG) surgery. Material and methods . Studied were 80 patients who underwent CABG in 2015-2016 years. In all the patients routine laboratory and instrumental tests were performed. Patients also underwent genetic polymorphisms of ММР -9 А 8202G and TIMP-1 C536T estimation with polymerase chain reaction. According to occurrence of postoperative atrial fibrillation (POAF) all the patients were divided into two groups: 1 group comprised 56 patients without POAF (81,8% males, mean age 65,9±4,0 years), 2 group — 24 patients with first detected episode of AF after CABG (875% males, mean age 67,7±5,4). Results . According to results of multivariate regression analysis the odds ratio of POAF development in patients with stable angina grade III was 1,8 (95% CI 0,5-75, p=0,4), NYHA III — 0,85 (95% CI 0,2-3,5, p=0,55), history of CAD more than 20 months — 1,8 (95% CI 1,2-8,1, p=0,03), LA diameter more than 39 mm — 4,2 (95% CI 1,6-9,5, p<0,0001), allele G MMP-9 A8202G — 2,6 (95% CI 1,2-75, p=0,03). Conclusion . In elderly patients undergoing coronary artery bypass graft surgery left atrial diameter more than 39 mm, history of coronary artery disease more than 20 months and the presence of G allele of MMP-9 A820G are significantly associated with postoperative atrial fibrillation occurrence.