Atrial fibrillation in the elderly

  • Jane Chen
  • Michael W. Rich
Article

Opinion statement

Atrial fibrillation (AF) is the most common sustained arrhythmia in adults, and its incidence and prevalence increase progressively with age. As a result, AF-associated morbidity and mortality increase with age. Therefore, because even asymptomatic AF markedly increases the risk of stroke and other embolic events, aggressive treatment is warranted in order to avoid the potentially devastating sequelae of this condition. Goals for the treatment of AF in the elderly population should primarily focus on alleviation of symptoms and prevention of strokes, while minimizing potential toxic effects of polypharmacy. Rate control should be optimized with atrioventricular (AV) nodal-blocking agents. The decision of anticoagulation should be individualized for each patient, balancing the risk of stroke against the risk for major bleeding complications. In elderly patients without symptoms, rate control and anticoagulation is the preferred method of treatment. Antiarrhythmic therapy to maintain sinus rhythm is generally reserved for patients with significant symptoms attributable to AF. However, simply maintaining sinus rhythm has not been proven to decrease stroke risk; therefore, longterm anticoagulation is recommended even in patients who are in sinus rhythm on antiarrhythmic drugs. AV nodal ablation with implantation of a pacemaker is a safe and excellent method of rate control for elderly patients who do not respond adequately to pharmacotherapy. Other invasive procedures, such as pulmonary vein isolation and Cox-Maze operations, are associated with high risks of complications in the elderly and are generally not recommended. Postoperative AF is common in the elderly population, and its development in high-risk patients should be anticipated and promptly treated to avoid potential hemodynamic compromise and prolonged hospitalization.

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References and Recommended Reading

  1. 1.
    Falk R: Atrial fibrillation. N Engl J Med 2001, 344:1067–1078. An excellent review and overall summary of management of AF.PubMedCrossRefGoogle Scholar
  2. 2.
    Wolf PA, Abbbott RD, Kannel WB: Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 1991, 22:983–988.PubMedGoogle Scholar
  3. 3.
    Stroke Prevention in Atrial Fibrillation Study: final results [no authors listed]. Circulation 1991, 84:527–539.Google Scholar
  4. 4.
    Beyth RJ, Quinn L, Landefeld CS: A multicomponent intervention to prevent major bleeding complications in older patients receiving warfarin. A randomized, controlled trial. Ann Intern Med 2000, 133:687–695.PubMedGoogle Scholar
  5. 5.
    Wyse DG, Waldo AL, DiMarco JP, et al.: A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002, 347:1825–1833. The most important paper on AF in recent years, addressing the age-old controversy on rhythm control versus rate control.PubMedCrossRefGoogle Scholar
  6. 6.
    Ommen SR, Odell JA, Stanton MS: Atrial arrhythmias after cardiothoracic surgery. N Engl J Med 1997, 36:1429–1434.CrossRefGoogle Scholar
  7. 7.
    Rawles JM: What is meant by a “controlled” ventricular rate in atrial fibrillation? Br Heart J 1990, 63:157–161.PubMedGoogle Scholar
  8. 8.
    Fihn SD, Callahan CM, Martin DC, et al.: The risk for and severity of bleeding complications in elderly patients treated with warfarin. Ann Intern Med 1996, 124:970–979.PubMedGoogle Scholar
  9. 9.
    Hylek EM, Skates SJ, Sheehan MA, et al.: An analysis of the lowest effective intensity of prophylactic anticoagulation for patients with nonrheumatic atrial fibrillation. N Engl J Med 1996, 335:540–546.PubMedCrossRefGoogle Scholar
  10. 10.
    Bleeding during antithrombotic therapy in patients with atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators [no authors listed]. Arch Intern Med 1996, 156:409–416.Google Scholar
  11. 11.
    Palareti F, Hirsh J, Legnani C, et al.: Oral anticoagulation treatment in the elderly: a nested, prospective, case-control study. Arch Intern Med 2000, 160:470–478.PubMedCrossRefGoogle Scholar
  12. 12.
    Albers GW, Dalen JE, Laupacis A, et al.: Antithrombotic therapy in atrial fibrillation. Chest 2001, 119:194S-206S. Consensus recommendations on the use of antithrombotic therapy in the treatment of AF based on a comprehensive review of available evidence.PubMedCrossRefGoogle Scholar
  13. 13.
    Fuster V, Ryden LE, Asinger RW, et al.: ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. Circulation 2001, 104:2118–2150. Current guidelines for the management of AF.PubMedGoogle Scholar
  14. 14.
    Intravenous digoxin in acute atrial fibrillation: results of a randomized, placebo-controlled multicentre trial in 239 patients. The Digitalis in Acute Atrial Fibrillation (DAAF) Trial Group [no authors listed]. Eur Heart J 1997, 18:649–654.Google Scholar
  15. 15.
    Roberts SA, Diaz C, Nolan PE, et al.: Effectiveness and cost of digoxin treatment for atrial fibrillation and flutter. Am J Cardiol 1993, 72:567–573.PubMedCrossRefGoogle Scholar
  16. 16.
    Farshi R, Kistner D, Sarma JSM, et al.: Ventricular rate control in chronic atrial fibrillation during daily activity and programmed exercise: a crossover open-label study of five drug regimens. J Am Coll Cardiol 1999, 33:304–310.PubMedCrossRefGoogle Scholar
  17. 17.
    Raithore SS, Wang Y, Krumholz HM: Sex-based differences in the effect of digoxin for the treatment of heart failure. N Engl J Med 2002, 347:1403–1411.CrossRefGoogle Scholar
  18. 18.
    Raithore SS, Curtis JP, Wang Y, et al.: Association of serum digoxin concentration and outcomes in patients with heart failure. JAMA 2003, 289:871–878.CrossRefGoogle Scholar
  19. 19.
    Hjalmarson A, Elmfeldt D, Herlitz J, et al.: Effect on mortality of metoprolol in acute myocardial infarction. A double-blind randomised trial. Lancet 1981, 2:823–827.PubMedCrossRefGoogle Scholar
  20. 20.
    Connolly SJ, Cybulsky I, Lamy A, et al.: Double-blind, placebo-controlled, randomized trial of prophylactic metoprolol for reduction of hospital length of stay after heart surgery: the beta-Blocker Length Of Stay (BLOS) study. Am Heart J 2003, 145:226–232.PubMedCrossRefGoogle Scholar
  21. 21.
    Coplen SE, Antman EM, Berlin JA, et al.: Efficacy and safety of quinidine therapy for maintenance of sinus rhythm after cardioversion. A meta-analysis of randomized control trials. Circulation 1991, 82:1106–1116.Google Scholar
  22. 22.
    Volgman AS, Carberry PA, Stambler B, et al.: Conversion efficacy and safety of intravenous ibutilide compared with intravenous procainamide in patients with atrial flutter or fibrillation. J Am Coll Cardiol 1998, 31:1414–1419.PubMedCrossRefGoogle Scholar
  23. 23.
    Echt DS, Liebson PR, Mitchell LB, et al.: The Cardiac Arrhythmia Suppression Trial. N Engl J Med 1991, 324:781–788.PubMedCrossRefGoogle Scholar
  24. 24.
    Nystrom U, Edvardsson N, Berggren H, et al.: Oral sotalol reduces the incidence of atrial fibrillation after coronary artery bypass surgery. Thorac Cardiovasc Surg 1993, 41:34–37.PubMedGoogle Scholar
  25. 25.
    Falk RH, Pollak A, Singh SN, et al.: Intravenous dofetilide, a class III antiarrhythmic agent, for the termination of sustained atrial fibrillation or flutter. Intravenous Dofetilide Investigators. J Am Coll Cardiol 1997, 29:385–390.PubMedCrossRefGoogle Scholar
  26. 26.
    Torp-Pedersen C, Moller M, Block-Thomsen PE, et al.: Dofetilide in patients with congestive heart failure and left ventricular dysfunction. N Engl J Med 1999, 341:857–865.PubMedCrossRefGoogle Scholar
  27. 27.
    Pedersen OD, Bagger H, Keller N, et al.: Efficacy of dofetilide in the treatment of atrial fibrillation-flutter in patients with reduced left ventricular function. A Danish Investigations of Arrhythmia and Mortality on Dofetilide (DIAMOND) substudy. Circulation 2001, 104:292–296.PubMedGoogle Scholar
  28. 28.
    Oral H, Souza JJ, Michaud GF, et al.: Facilitating transthoracic cardioversion of atrial fibrillation with ibutilide pretreatment. N Engl J Med 1999, 340:1849–1854.PubMedCrossRefGoogle Scholar
  29. 29.
    Cotter G, Blatt A, Kaluski E, et al.: Conversion of recent onset paroxysmal atrial fibrillation to normal sinus rhythm: the effect of no treatment and high-dose amiodarone. A randomized, placebo-controlled study. Eur Heart J 1999, 20:1833–1842.PubMedCrossRefGoogle Scholar
  30. 30.
    Kochiadakis GE, Igoumenidis NE, Parthenakis FI, et al.: Amiodarone versus propafenone for conversion of chronic atrial fibrillation: results of a randomized, controlled study. J Am Coll Cardiol 1999, 33:966–971.PubMedCrossRefGoogle Scholar
  31. 31.
    Daoud EG, Strickberger SA, Man KC, et al.: Preoperative amiodarone as prophylaxis against atrial fibrillation after heart surgery. N Engl J Med 1997, 337:1785–1791.PubMedCrossRefGoogle Scholar
  32. 32.
    Klein AL, Grimm RA, Murray RD, et al.: Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 2001, 344:1411–1420. Randomized trial comparing TEE-guided cardioversion to conventional cardioversion in patients with AF. Although thromboembolic event rates were similar, there were fewer bleeding episodes in the echocardiography-guided group, reflecting shorter duration of anticoagulation.PubMedCrossRefGoogle Scholar
  33. 33.
    Gentile F, Elhendy A, Khandheria BK, et al.: Safety of electrical cardioversion in patients with atrial fibrillation. Mayo Clin Proc 2002, 77:897–904.PubMedCrossRefGoogle Scholar
  34. 34.
    Ozcan C, Jahangir A, Friedman P, et al.: Long-term survival after ablation of the atrioventricular node and implantation of a permanent pacemaker in patients with atrial fibrillation. N Engl J Med 2001, 344:1043–1051. Atrioventricular nodal ablation with permanent pacemaker implantation was associated with improved quality of life and equivalent survival compared to standard therapy in patients with AF.PubMedCrossRefGoogle Scholar
  35. 35.
    Connolly SJ, Kerr CR, Gent M, et al.: Effects of physiologic pacing versus ventricular pacing on the risk of stroke and death due to cardiovascular causes. N Engl J Med 2000, 342:1385–1391.PubMedCrossRefGoogle Scholar
  36. 36.
    Prakash A, Saksena S, Hill M, et al.: Acute effects of dual-site right atrial pacing in patients with spontaneous and inducible atrial flutter and fibrillation. J Am Coll Cardiol 1997, 29:1007–1014.PubMedCrossRefGoogle Scholar
  37. 37.
    Garrigue S, Barold SS, Cazeau S, et al.: Prevention of atrial arrhythmias during DDD pacing by atrial overdrive. Pacing Clin Electrophysiol 1998, 21:1751–1759.PubMedCrossRefGoogle Scholar
  38. 38.
    Wellens HJJ, Lau CP, Luderitz B, et al.: Atrioverter: an implantable device for the treatment of atrial fibrillation. Circulation 1998, 98:1651–1656.PubMedGoogle Scholar
  39. 39.
    Haïssaguerre M, Jaïs P, Shah DC, et al.: Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998, 339:659–666.PubMedCrossRefGoogle Scholar
  40. 40.
    Oral H, Knight BP, Özaydin M, et al.: Segmental ostial ablation to isolate the pulmonary veins during atrial fibrillation: feasibility and mechanistic insights. Circulation 2002, 106:1256–1262.PubMedCrossRefGoogle Scholar
  41. 41.
    Huang DT, Monahan KM, Zimetbaum P, et al.: Hybrid pharmacologic and ablative therapy: a novel and effective approach for the management of atrial fibrillation. J Cardiovasc Electrophysiol 1998, 9:462–469.PubMedCrossRefGoogle Scholar
  42. 42.
    Ad N, Cox JL: Stroke prevention as an indication for the Maze procedure in the treatment of atrial fibrillation. Semin Thorac Cardiovasc Surg 2000, 12:56–62.PubMedGoogle Scholar
  43. 43.
    Cox JL, Ad N, Palazzo T, et al.: Current status of the Maze procedure for the treatment of atrial fibrillation. Semin Thorac Cardiovasc Surg 2000, 12:15–19.PubMedCrossRefGoogle Scholar
  44. 44.
    Halperin JL: Embolism in patients with nonvalvular atrial fibrillation. Paper presented at the American College of Cardiology Annual Scientific Session. Chicago, IL; March 30 to April 2, 2003.Google Scholar
  45. 45.
    Page RL, Tilsch TW, Connolly SJ, et al.: Asymptomatic or "silent" atrial fibrillation: frequency in untreated patients and patients receiving azimilide. Circulation 2003, 107:1141–1145.PubMedCrossRefGoogle Scholar
  46. 46.
    Kawase A, Ikeda T, Nakazawa K, et al.: Widening of the excitable gap and enlargement of the core of reentry during atrial fibrillation with a pure sodium channel blocker in canine atria. Circulation 2003, 107:905–910.PubMedCrossRefGoogle Scholar
  47. 47.
    Sievert H, Lesh MD, Trepels T, et al.: Percutaneous left atrial appendage transcatheter occlusion to prevent stroke in high-risk patients with atrial fibrillation: early clinical experience. Circulation 2002, 105:1887–1889.PubMedCrossRefGoogle Scholar
  48. 48.
    Crystal E, Lamy A, Connolly SJ, et al.: Left Atrial Appendage Occlusion Study (LAAOS): a randomized clinical trial of left atrial appendage occlusion during routine coronary artery bypass graft surgery for long-term stroke prevention. Am Heart J 2003, 145:174–178.PubMedCrossRefGoogle Scholar
  49. 49.
    Kress DC, Sra J, Krum D, et al.: Radiofrequency ablation of atrial fibrillation during mitral valve surgery. Semin Thorac Cardiovasc Surg 2002, 14:210–218.PubMedGoogle Scholar
  50. 50.
    Maessen JC, Nijs JF, Smeets JL, et al.: Beating-heart surgical treatment of atrial fibrillation with microwave ablation. Ann Thorac Surg 2002, 74:S1307-S1311.PubMedCrossRefGoogle Scholar
  51. 51.
    Manasse E, Infante M, Ghiselli S, et al.: A video-assisted thoracoscopic technique to encircle the four pulmonary veins: a new surgical intervention for atrial fibrillation ablation. Heart Surg Forum 2002, 5:337–339.PubMedGoogle Scholar

Copyright information

© Current Science Inc 2003

Authors and Affiliations

  • Jane Chen
    • 1
  • Michael W. Rich
    • 1
  1. 1.Cardiovascular DivisionWashington University School of MedicineSt. LouisUSA

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