Atrial Fibrillation in the Elderly

The prevalence of atrial fibrillation is 11 % in persons older than 70 years and rises to 17% in those aged 84 years or more. One-year mortality ranges from 0.2 to 16%, being highest in elderly patients, and is associated with a 4.8-fold increased risk of stroke. Atrial fibrillation can be cardioverted to normal sinus rhythm electrically or pharmacologically and rapid ventricular rate can be controlled with drugs. While anticoagulation prevents embolic events in those with atrial fibrillation, the decision to anticoagulate should be based on an assessment of the risk/benefit ratio.     

Atrial Fibrillation in the Elderly

Atrial fibrillation is a common cardiac arrhythmia found in the elderly. The cornerstones of therapy are prevention of thromboembolism with anticoagulation therapy, control of ventricular rate, and restoration of sinus rhythm when feasible. The use of warfarin therapy has been shown to be effective in reducing strokes, but management can be difficult, and the development of new oral anticoagulant medications is an area of ongoing research. In addition, new strategies to promote the maintenance of sinus rhythm, including new pharmacotherapy as well as catheter-based and surgical procedures, are becoming more widespread. Data regarding the use of more invasive modalities in elderly patients are accumulating. In this article, we will give a brief overview of current management options of atrial fibrillation, and will focus specifically on new data pertaining to the role of these strategies in elderly patients.     

Atrial Fibrillation in the Elderly

Atrial fibrillation is a common cardiac arrhythmia affecting up to 5% of people over the age of 65 years. The elderly are less well able to withstand the hemodynamic stress of new-onset and rapid atrial fibrillation. Advancing age is a predisposing factor for atrial fibrillation itself and for its complications. The main adverse outcomes caused by atrial fibrillation include peripheral embolic events, particularly stroke and left ventricular dysfunction. Sinus rhythm is of special importance in the elderly as it may be the main way to reduce the thromboembolic risks of atrial fibrillation. When sinus rhythm cannot be restored and maintained, control of heart rate by pharmacologic or other means has advantage in itself. The long-term benefits of aspirin and warfarin in patients with chronic nonvalvular atrial fibrillation have been demonstrated by recent trials. However, these benefits do not universally extend to patients above the age of 75 years, and thoughtful individualized antithrombotic treatment is needed for the elderly patient with atrial fibrillation.     

Atrial Fibrillation Management in Elderly

Atrial fibrillation (AF) in older adults is inherently more clinically challenging than sinus rhythm because it is associated with diminished functional capacity and quality of life, as well as higher incidence of mortality, stroke, and coronary events. AF with a rapid ventricular rate is particularly likely to cause demand ischemia, heart failure with preserved ejection fraction (HFPEF), as well as tachycardia-related cardiomyopathy. Indications for direct-current cardioversion, pharmacological cardioversion, rate control, and nondrug therapies are discussed. Differences in clinical outcome based on ventricular rate control versus drug treatment to maintain sinus rhythm are also reviewed. Indications for anticoagulation for chronic or paroxysmal AF are included, including long-term warfarin and direct thrombin inhibitors (dabigatran, rivaroxaban, or apixaban) and/or aspirin.     

Atrial Fibrillation in Heart Failure: A Comprehensive Review

Chronic heart failure and atrial fibrillation are 2 major disorders that are closely linked. Their coexistence is associated with adverse prognosis. Both share several common predisposing conditions, but their interaction involves complex ultrastructural, electrophysiologic, and neurohormonal processes that go beyond mere sharing of mutual risk factors. Rate control approach remains the standard therapy for atrial fibrillation in heart failure because current strategies at rhythm control have so far failed to positively impact mortality and morbidity. This is largely because of the shortcomings of current pharmacologic anti-arrhythmic agents. Surgical and catheter-based therapies are promising, but long-term data are lacking. The role of non-anti-arrhythmic therapeutic agents also is being explored. Further progress toward improved understanding the complex relationship between atrial fibrillation and heart failure should improve management strategies.     

老年人心房颤动的药物治疗

心房颤动是老年人遇到的最常见的心律失常之一,重者可以导致肢体栓塞或脑卒中。虽然心房颤动诊断已不是难题,且心房颤动的治疗经历了大的变化,但满意的药物治疗还未被发展。现就老年人心房颤动患者药物治疗方面做一综述。     

Management of Atrial Fibrillation in Elderly Adults

Driven in large part by the aging of the population and the increasing prevalence of cardiovascular comorbidities associated with atrial fibrillation (AF), there is a burgeoning epidemic of AF in elderly adults. Although there is a large body of literature to guide management of people with AF, elderly adults with AF are frequently underrepresented in clinical trials. This review provides a contemporary update on management of elderly adults with AF with a particular focus on the two main clinical challenges that AF poses: stroke risk reduction and control of symptoms. The evidence to support novel AF treatment strategies in elderly adults is reviewed, including novel oral anticoagulants and left atrial appendage closure for stroke risk reduction and catheter ablation for control of symptoms.     

A Review of Surgery for Atrial Fibrillation

A Review of Surgery for Atrial Fibrillation. Atrial fibrillation is the most common of all sustained cardiac arrhythmias, yet it has no effective medical or surgical therapy. During the past decade, multipoint computerized electrophysiologic mapping systems were used to map both experimental and human atrial fibrillation. On the basis of these studies, a new surgical procedure was developed for atrial fibrillation. Between September 25, 1987, and July 1, 1991, this procedure was applied in 22 patients with paroxysmal atrial flutter (n = 2), paroxysmal atrial fibrillation (n = 11), or chronic atrial fibrillation (n = 9) of 2 to 21 years duration. All patients were refractory to all antiarrhythmic medications, and each patient failed to receive the desired therapeutic benefits of an average of five drugs administered preoperatively. There were no operative deaths and all perioperative morbidity resolved. All 22 patients have been successfully treated for atrial fibrillation with surgery alone. Preservation of atrial transport function has been documented in all patients postoperatively, and all have experienced marked clinical improvement.     

Atrioesophageal Fistula in the Era of Atrial Fibrillation Ablation: A Review

The purpose of this review is to understand the epidemiology, clinical features, etiopathogenesis, and management of atrioesophageal fistula (AEF) after atrial fibrillation (AF) ablation. The incidence of AEF after AF ablation is 0.015%-0.04%. The principal clinical features include fever, dysphagia, upper gastrointestinal bleeding, sepsis, and embolic strokes. The close proximity of the esophagus to the posterior left atrial wall is responsible for esophageal injury during ablation. Prophylactic proton pump inhibitors, esophageal temperature monitoring, visualization of the esophagus during catheter ablation, esophageal protection devices, and avoidance of energy delivery in close proximity to the esophagus play an important role in preventing esophageal injury. Early surgical repair or esophageal stenting are the mainstay of treatment. Eliminating esophageal injury during AF ablation is of utmost importance in preventing AEF. A high index of suspicion and early intervention is necessary to prevent fatal outcomes.     

Underuse of Oral Anticoagulants in Atrial Fibrillation: A Systematic Review

Background

Atrial fibrillation is associated with substantial mortality and morbidity from stroke and thromboembolism. Despite an efficacious oral anticoagulation therapy (warfarin), atrial fibrillation patients at high risk for stroke are often under-treated. This systematic review compares current treatment practices for stroke prevention in atrial fibrillation with published guidelines.

Methods

Literature searches (1997-2008) identified 98 studies concerning current treatment practices for stroke prevention in atrial fibrillation. The percentage of patients eligible for oral anticoagulation due to elevated stroke risk was compared with the percentage treated. Under-treatment was defined as treatment of <70% of high-risk patients.

Results

Of 54 studies that reported stroke risk levels and the percentage of patients treated, most showed underuse of oral anticoagulants for high-risk patients. From 29 studies of patients with prior stroke/transient ischemic attack who should all receive oral anticoagulation according to published guidelines, 25 studies reported under-treatment, with 21 of 29 studies reporting oral anticoagulation treatment levels below 60% (range 19%-81.3%). Subjects with a CHADS₂ (congestive heart failure, hypertension, age >75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score ≥2 also were suboptimally treated, with 7 of 9 studies reporting treatment levels below 70% (range 39%-92.3%). Studies (21 of 54) using other stroke risk stratification schemes differ in the criteria they use to designate patients as “high risk,” such that direct comparison is not possible.

Conclusions

This systematic review demonstrates the underuse of oral anticoagulation therapy for real-world atrial fibrillation patients with an elevated risk of stroke, highlighting the need for improved therapies for stroke prevention in atrial fibrillation.     

A Contemporary Review on the Genetic Basis of Atrial Fibrillation

Atrial fibrillation is the most common sustained cardiac arrhythmia, and affected individuals suffer from increased rates of heart failure, stroke, and death. Despite the enormous clinical burden that it exerts on patients and health care systems, contemporary treatment strategies have only modest efficacy that likely stems from our limited understanding of its underlying pathophysiology. Epidemiological studies have provided unequivocal evidence that the arrhythmia has a substantial heritable component. Subsequent investigations into the genetics underlying atrial fibrillation have suggested that there is considerable interindividual variability in the pathophysiology characterizing the arrhythmia. This heterogeneity may partly account for the poor treatment efficacy of current therapies. Subdividing atrial fibrillation into mechanistic subtypes on the basis of genotype illustrates the heterogeneous nature of the arrhythmia and may ultimately help guide treatment strategies. A pharmacogenetic approach to the management of atrial fibrillation may lead to dramatic improvements in treatment efficacy and improved patient outcomes     

Impaired Kidney Function and Atrial Fibrillation in Elderly Subjects

BackgroundImpaired kidney function is associated with increased risk for cardiovascular events. We evaluated whether kidney function is associated with atrial fibrillation (AF) risk in elderly persons.Methods and ResultsSubjects were participants in the Cardiovascular Health Study (CHS), a population-based cohort of ambulatory elderly. Measures of kidney function were cystatin C and creatinine-based estimated glomerular filtration rate (eGFR). Among the 4663 participants, 342 (7%) had AF at baseline and 579 (13%) developed incident AF during follow-up (mean 7.4 years). In unadjusted analyses, cystatin C quartiles were strongly associated with prevalent AF with a nearly 3-fold odds in the highest quartile compared with the lowest (HR = 1.19, 95% CI [0.80-1.76] in quartile 2; HR = 2.00, 95% CI [1.38-2.88] in quartile 3; and HR = 2.87, 95% CI [2.03-4.07] in quartile 4). This increased risk for prevalent AF remained significant after multivariate adjustment. The risk for incident AF increased across cystatin C quartiles in the unadjusted analysis (HR = 1.37, 95% CI [1.07-1.75] in quartile 2; HR = 1.43, 95% CI [1.11-1.84] in quartile 3; and HR = 1.88, 95% CI [1.47-2.41] in quartile 4); however, after multivariate adjustment, these findings were no longer significant. An estimated GFR <60 mL·min·1.73 m² was associated with prevalent and incident AF in unadjusted, but not multivariate analyses.ConclusionsImpaired kidney function, as measured by cystatin C, is an independent marker of prevalent AF; however, neither cystatin C nor eGFR are predictors of incident AF.     

Atrial Fibrillation and Non-cardiovascular Diseases: A Systematic Review

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated withan unfavorable prognosis, increasing the risk of stroke and death. Althoughtraditionally associated with cardiovascular diseases, there is increasing evidenceof high incidence of AF in patients with highly prevalent noncardiovascular diseases,such as cancer, sepsis, chronic obstructive pulmonary disease, obstructive sleepapnea and chronic kidney disease. Therefore, considerable number of patients has beenaffected by these comorbidities, leading to an increased risk of adverseoutcomes.The authors performed a systematic review of the literature aiming to betterelucidate the interaction between these conditions.Several mechanisms seem to contribute to the concomitant presence of AF andnoncardiovascular diseases. Comorbidities, advanced age, autonomic dysfunction,electrolyte disturbance and inflammation are common to these conditions and maypredispose to AF.The treatment of AF in these patients represents a clinical challenge, especially interms of antithrombotic therapy, since the scores for stratification ofthromboembolic risk, such as the CHADS₂ andCHA₂DS₂VASc scores, and the scores for hemorrhagic risk, likethe HAS-BLED score have limitations when applied in these conditions.The evidence in this area is still scarce and further investigations to elucidateaspects like epidemiology, pathogenesis, prevention and treatment of AF innoncardiovascular diseases are still needed.