Atrial Fibrillation in the Elderly
Dr Martin J Gardner
QEII Health Sciences Centre and
Dalhousie University
Disclosure
• Speakers fees/ grants:
– Medtronic of Canada
– St Jude Canada
Atrial Fibrillation Management
• Review recommendations for:
– Prevention
– Investigation
– Stroke prevention
– Rhythm management
• Drugs
• Catheter ablation
• Indicate what I do
Atrial Fibrillation Guidelines
Canadian Cardiovascular Society 2011/2012
http://www.ccsguidelineprograms.ca/atrial-fibrillation-guidelines-program/
European Society of Cardiology/ European Heart Rhythm Association 2010
http://eurheartj.oxfordjournals.org/content/ehj/31/19/2369.full.pdf
2011 ACCF/AHA/HRS Focused Update on the
Management of Patients with AF
http://circ.ahajournals.org/content/123/1/104.extract
Case Study
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75 year old man
History of hypertension and diabetes
No cardiac history
Regular visit with you for BP check and complains of mild fatigue
Medications: losartan/HCTZ, metformin, ASA
Otherwise well
Height: 1.75 m
Weight: 98 kg
BP: 166/92
Pulse: irregular
Atrial Fibrillation
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Does he have symptoms?
What symptoms are caused by atrial fibrillation?
How do you control the symptoms?
Is there a risk of stroke?
How do you reduce the risk of stroke?
Can atrial fibrillation be prevented?
Cumulative Risk for AF
Figure 1
Lloyd-Jones DM, Wang TJ, Leip EP, Larson MG, Levy D, Vasan RS, et al. Lifetime risk for development of atrial
fibrillation: the Framingham Heart Study. Circulation. 2004 Aug 31;110(9): 1042-1046.
Prevalence of Atrial Fibrillation
Figure 2
Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV, et al. Prevalence of diagnosed atrial fibrillation in adults:
national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial
Fibrillation (ATRIA) Study. JAMA. 2001 May 9; 285(18): 2370-2375.
Assessment and
Prevention
“Upstream” Therapy Primary
Prevention
Agents Considered:
ACE inhibitors, Angiotensin receptor
blockers, Aldosterone antagonists
Statins, PUFAs
European Heart Rhythm Association, European Association for CardioThoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, et al.
Guidelines for the management of atrial fibrillation: the Task Force for the
Management of Atrial Fibrillation of the European Society of Cardiology
(ESC). Eur Heart J. 2010 Oct 31; 31(19): 2369-2429.
Etiology and Investigations
All patients with atrial fibrillation should have
a complete history and physical examination,
electrocardiogram, echocardiogram, basic
laboratory investigations.
Strong
Recommendation
Low Quality
Evidence
History
Establish Severity (including impact on QoL)
Identify Etiology
Identify reversible causes (hyperthyroidism, ventricular pacing, SVT,
exercise)
Identify factors whose treatment could reduce recurrent AF or improve
overall prognosis (i.e. hypertension, sleep apnea, left ventricular
dysfunction)
Identify potential triggers (i.e. alcohol, intensive aerobic training)
Identify potentially heritable causes of AF (particularly in lone AF)
Determine thrombo-embolic risk (e.g. CHADS2 Score)
Determine bleeding risk to guide appropriate anti-thrombotic therapy
Review prior pharmacologic therapy for AF, for efficacy and adverse effects
What I do for Elderly AF Patients
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Complete history, physical, ECG, ± Echocardiogram
Evaluate stroke risk
Document that symptoms are really from atrial fibrillation
Establish severity of AF for each patient
Look for all precipitating/ aggravating factors and treat
aggressively
• Treat hypertension with a view to rate controlling
medications and ACE I/ ARBs
• Don’t forget heart failure; sleep apnea
What I Do
• Recognize that every patient with A Fib is different
• There is no one way to treat A Fib
• Important to determine the impact of A Fib on the
persons well being (QoL)
Establish AF Severity
Use to Guide Therapeutic Approach
CCS
SAF Score
Impact on QOL
0
Asymptomatic
1
Minimal effect on QOL
Single episode of AF without heart failure
2
Minor effect of QOL
Mild awareness in persistent AF, or rare episodes (less
than a few per year) in paroxysmal
Moderate effect on QOL
Moderate awareness of symptoms on most days in
persistent AF, or more common episodes (more than
every few months) or more severe symptoms or both in
paroxysmal AF
Severe effect on QOL
Very unpleasant symptoms in persistent AF; frequent
and highly symptomatic paroxysmal AF; syncope due to
AF, CHF secondary to AF
3
4
Example
Dorian P, Cvitkovic SS, Kerr CR, Crystal E, Gillis AM, Guerra PG, et al. A novel, simple scale for assessing the symptom severity of
atrial fibrillation at the bedside: the CCS-SAF scale. Can J Cardiol 2006 Apr; 22(5): 383-386.
Management
Overview of AF Management
AF Detected
Detection and
Treatment of
Precipitating Causes
Overview of AF Management
AF Detected
Assessment of
Thromboembolic
Risk (CHADS2)
ASA
OAC
Stroke Risk - CHADS2
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Congestive heart failure
Hypertension
Age (>75)
Diabetes
Stroke/ TIA
Risk of Stroke
• With no risk factors
• With one risk factor
• With > one risk factor
1 %/yr
4-6%/yr
6-10%/yr
Risk of Bleeding
• HAS-BLED Score – one point each:
–
–
–
–
–
–
–
Uncontrolled hypertension
Renal dysfunction (CC <30)
Liver disease (bilirubin >2x; ALT/AST >3x)
Prior major bleeding
Age > 65
Medication (ASA)
Alcohol (>8 drinks/wk)
Risk of Bleeding
HAS-BLED Score
• 0
• 1-2
• 3 or more
0.9%/yr
3-4%/yr
>5%/yr
Annualized Rates of Warfarin-Associated
Extracranial and Intracranial Hemorrhage by
age (unadjusted)
Figure 2
Fang MC, Go AS, Hylek EM, Chang Y,
Henault LE, Jensvold NG, et al. Age and
risk factor of warfarin-associated
hemorrhage: the Anticoagulation and
Risk Factors in Atrial Fibrillation Study. J
Am Geriatr Soc. 2006 Aug; 54(8): 1231 –
1236.
Figure 1
Macle L, Cairns JA, Andrade JG, Mitchell LB, Nattell S,
Verma A, et al. The 2014 atrial fibrillation guidelines
companion: a practical approach to the use of the
Canadian Cardiovascular Society guidelines. Can J
Cardiol. 2015 Oct; 31(10): 1207-1218.
Figure 1
Macle L, Cairns JA, Andrade JG, Mitchell LB, Nattell S, Verma A, et al. The 2014 atrial fibrillation guidelines companion: a
practical approach to the use of the Canadian Cardiovascular Society guidelines. Can J Cardiol. 2015 Oct; 31(10): 12071218.
Figure 2
Skanes AC, Healey JS, Cairns
JA, Dorian P, Gillis AM,
McMurtry MS, et al. Focused
2012 update of the Canadian
Cardiovascular Society atrial
fibrillation guidelines:
recommendations for stroke
prevention and rate/rhythym
control. Can J Cardiol. 2012 Mar
- Apr; 28(2): 125 – 136.
Figure 2
Skanes AC, Healey JS, Cairns
JA, Dorian P, Gillis AM,
McMurtry MS, et al. Focused
2012 update of the Canadian
Cardiovascular Society atrial
fibrillation guidelines:
recommendations for stroke
prevention and rate/rhythym
control. Can J Cardiol. 2012 Mar
- Apr; 28(2): 125 – 136.
Figure 2
Skanes AC, Healey JS, Cairns
JA, Dorian P, Gillis AM,
McMurtry MS, et al. Focused
2012 update of the Canadian
Cardiovascular Society atrial
fibrillation guidelines:
recommendations for stroke
prevention and rate/rhythym
control. Can J Cardiol. 2012 Mar
- Apr; 28(2): 125 – 136.
Figure 2
Skanes AC, Healey JS, Cairns
JA, Dorian P, Gillis AM,
McMurtry MS, et al. Focused
2012 update of the Canadian
Cardiovascular Society atrial
fibrillation guidelines:
recommendations for stroke
prevention and rate/rhythym
control. Can J Cardiol. 2012 Mar
- Apr; 28(2): 125 – 136.
Which Anticoagulant Drug?
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Warfarin
Dabigatran
Rivaroxaban
Apixaban
Edoxaban
NOACs
DOACs
Which Anticoagulant Drug?
• Warfarin
– Inexpensive
– Requires INR measurements
– May be more difficult to maintain
therapeutic INR
– Anticoagulation can be reversed
Which Anticoagulant Drug?
• DOACs
– Expensive and not always covered
– Does not require INR measurements
– May cause excess bleeding with renal
impairment and low body weight (need to
calculate creatinine clearance)
– Creatinine needs to be monitored
– Non-reversal/ Short half life
Renal Impairment
1. Hart RG, Eikelboom JW, Brimble KS, McMurtry MS, Ingram AJ. Stroke prevention in atrial fibrillation patients with chronic kidney
disease. Can J Cardiol. 2013 Jul; 29(7): S71 – 78.
2. Olesen JB, Lip GY, Kamper AL, Hommel K. Kober L, Lane DA, et al. Stroke and bleeding in atrial fibrillation with chronic kidney
disease. N Engl J Med. 2012 Aug 16; 367(7): 625 – 35.
3. Capodanno D, Angiolillo DJ. Antithrombotic therapy in patients with chronic kidney disease. Circulation. 2012 May 29; 125(21): 2649 –
2661.
ROCKET AF: Rivaroxaban in Patients With
AF and Moderate Renal Impairment
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
Patients with AF and reduced renal
function have increased risk of stroke
and bleeding
2,950 patients (20.7%) had moderate
renal impairment (CrCl 30–49 mL/min)
Results

Efficacy and safety results with
reduced-dose rivaroxaban (15 mg OD
for patients with CrCl 30–49 mL/min)
versus dose-adjusted warfarin were
consistent with the overall trial results
Conclusion
 Results support use of rivaroxaban as
an effective alternative to warfarin for
stroke prevention in patients with
moderate renal impairment
Primary endpoint: stroke/SE
Cumulative event rate (%)
Background/rationale
6
2.8%/yr
Warf. CrCl 30–49 mL/min
Riva. CrCl 30–49 mL/min
Warf. overall
Riva. overall
5
4
2.3%/yr
2.2%/yr
1.7%/yr
3
2
HR (95% CI) riva. vs. warf.:
CrCl 30–49 mL/min: 0.84 (0.57–1.23)
CrCl overall: 0.79 (0.66–0.96)
1
0
0
120
Major bleeding
Critical
ICH
Fatal
240 360 480 600 720
Days from randomization
CrCl 30–49
mL/min
(%/year)
Riva.
Warf.
4.49
4.70
0.76
1.39
0.71
0.88
0.28
0.74
840
CrCl ≥50
mL/min
(%/year)
Riva. Warf.
3.39
3.17
0.83
1.13
0.44
0.71
0.23
0.43
Fox KAA, Piccini JP, Wojdyla D, Becker RC, Halperin JL, Nessel CC, et al. Prevention of stroke and systemic embolism with rivaroxaban
compared with warfarin in patients with non-valvular atrial fibrillation and moderate renal impairment. Eur Heart J. 2011 Oct; 32(19):2387–2394;
Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med.
2011 Sept 8; 365(10):883–891.
pvalue
(int.)
0.48
0.39
0.51
0.53
Macle L, Cairns JA, Andrade JG, Mitchell LB, Nattell S, Verma A, et al. The 2014 atrial fibrillation guidelines companion: a
practical approach to the use of the Canadian Cardiovascular Society guidelines. Can J Cardiol. 2015 Oct; 31(10): 12071218.
Which Anticoagulant Drug?
•
•
•
•
•
Warfarin
Dabigatran
Rivaroxaban
Apixaban
Edoxaban
NOACs
DOACs
Overview of AF Management
AF Detected
Management of
Arrhythmia
Rate
Control
Rhythm
Control
Goals of AF Arrhythmia
Management
• Identify and treat underlying structural heart disease and
other predisposing conditions
• Relieve symptoms
• Improve functional capacity/quality of life
• Reduce morbidity/mortality associated with AF/AFL
– Reduce/prevent emergency room visits or hospitalizations
secondary to AF/AFL
– Prevent stroke or systemic thromboembolism
Rate or Rhythm Control?
• How do you decide if you are going to pursue rate or
rhythm control for a patient with AF?
• No right or wrong answer
• Often, the two are simultaneous:
– Rhythm control requires good rate control when
patient goes back into AF
• Need to continuously re-evaluate the strategy as the
AF progresses
– What may have been a good initial strategy may
no longer be warranted
What I Do
• Let symptoms be your guide
• Most elderly patients will benefit from rate control
• Use rhythm control only when there are more symptoms
due to AF and less underlying heart disease
• Be aggressive with rate control
Rate Control Drug Choices
No Heart
Disease
Hypertension
CAD
β-blocker
Diltiazem
Verapamil
Combination Rx
Digitalis†
β-blocker*
Diltiazem
Verapamil
Heart Failure
β-blocker
± digitalis
*β-blockers preferred in CAD
†Digitalis may be considered as
monotherapy in sedentary individuals
What is Optimal Target Heart Rate?
• RACE II suggested that strict rate control (< 80 bpm
at rest, < 110 bpm with activity) was no different
compared to lenient strategy (< 110 bpm at rest)
• However, actual HR in both groups were 75 and 86
bpm respectively
• Thus, the trial was not that lenient
• Few patients had HR > 100 bpm
Van Gelder IC, Groenveld HF, Crijns HJ, Tuininga YS, Tijssen JG, Alings AM, et al. Lenient versus strict
rate control in patients with atrial fibrillation. N Engl J Med. 2010 Apr 15; 362(15): 1363-73.
What is Optimal Target Heart Rate?
Figure 2
Van Gelder IC, Groenveld
HF, Crijns HJ, Tuininga
YS, Tijssen JG, Alings AM,
et al. Lenient versus strict
rate control in patients with
atrial fibrillation. N Engl J
Med. 2010 Apr 15;
362(15): 1363-73.
What I Do – Rate Control
• Measure rate at rest and with exercise
• Accept a resting HR below 100/min
• Be aware that persistent high heart rates can result in a
tachycardia induced cardiomyopathy
• Use combination therapy if needed
Principles of Antiarrhythmic Drug
Therapy to Maintain Sinus
Rhythm
1.
2.
3.
4.
5.
6.
Treatment is motivated by attempts to reduce symptoms
Efficacy of antiarrhythmic drugs is modest
Clinically successful antiarrhythmic drug therapy may reduce
rather than eliminate recurrence of AF
If one antiarrhythmic drug ‘fails’ a clinically acceptable response
may be achieved with another agent
Drug-induced proarrhythmia or side-effects are frequent
Safety rather than efficacy considerations should primarily guide
the choice of antiarrhythmic agent
Antiarrhythmic Drug Choices
Normal Ventricular Function
Dronedarone
Flecainide*
Propafenone*
Sotalol
Catheter Ablation
Amiodarone
* Class I agents should be AVOIDED in CAD
They should be combined with AV-nodal blocking agents
Sotalol contraindicated in women >65 yrs taking diuretics
Antiarrhythmic Drug Choices
In The Elderly
Dronedarone
Flecainide*
Propafenone*
Sotalol
Catheter Ablation
Amiodarone
What I Do
• Use anti-arrhythmic medications for elderly patients with
persistent and bothersome symptoms due to A Fib
• Normal heart – Sotalol/ Amiodarone
• Abnormal heart – Amiodarone
• Goal is to REDUCE episodes (not eliminate)
Rhythm Control Does Not
Replace Anticoagulation
• No evidence that AF reduction via antiarrhythmic therapy
reduces the risk of stroke/thromboembolism
• Patients must continue on appropriate anticoagulation
according to their individual embolic risk (CHADS2 score)
Catheter Ablation
Systematic Review of RCTs
Ablation vs Drug Rx
Ablation
Control
RR
95% CI
Forleo 2009
13/16
6/13
1.76
0.94, 3.31
Jais 2008
23/53
13/59
1.97
1.11, 3.48
Krittyaphong 2003
9/11
4/10
2.05
0.91, 4.59
Wazni 2005
31/35
12/32
2.36
1.49, 3.75
Wilber 2010
56/106
10/61
3.22
1.78, 5.84
Combined
132/221
45/175
2.26
1.74, 2.94
Ablation
Control
RR
95% CI
Forleo 2009
28/35
9/22
1.96
1.15, 3.32
Krittyaphong 2003
3/4
3/6
1.50
0.56, 4.00
Oral 2006
32/77
3/69
9.56
3.06, 29.8
Stabile 2006
16/26
2/19
5.85
1.52, 22.5
Combined
79/142
17/116
3.29
1.29, 8.41
•
Favours AAD
Favours RFA
•
Paroxysmal AF
Persistent AF
uniformly demonstrate large differences in
recurrence of AF
RR 2.26 and 3.29 in favour of ablation vs AAD
after a single procedure
Parkash R, Tang ASL, Sapp JL, Wells G. Approach to the catheter ablation technique of paroxysmal and persistent atrial
fibrillation: a meta-analysis of the randomized controlled trials. J Cardiovasc Electrophysiol. 2011 Jul; 22(7): 729 – 738.
We recommend catheter ablation of AF in
patients who remain symptomatic
following adequate trials of anti-arrhythmic
drug therapy and in whom a rhythm
control strategy remains desired.
Strong Recommendation
Moderate Quality
Evidence
We suggest catheter ablation to maintain
sinus rhythm in select patients with
symptomatic AF and mild-moderate
structural heart disease who are
refractory or intolerant to at least one antiarrhythmic medication.
Conditional
Recommendation
Moderate Quality
Evidence
We suggest catheter ablation to maintain
sinus rhythm as first-line therapy for relief
of symptoms in highly selected patients
with symptomatic, paroxysmal AF.
Conditional
Recommendation
Low Quality Evidence
Values and Preferences:
These recommendations recognize that the balance of risk with ablation and benefit in symptom relief and improvement in
quality of life must be individualized. They also recognize that patients may have relative or absolute cardiac or non-cardiac
contra-indications to specific medications.
Case Study
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75 year old man
History of hypertension and diabetes
No cardiac history
Regular visit with you for BP check and complains of mild fatigue
Medications: losartan/HCTZ, metformin, ASA
Otherwise well
Height: 1.75 m
Weight: 98 kg
BP: 166/92
Pulse: irregular
Management
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Manage stroke risk – anticoagulation
Weight
BP control
Assess rate with exercise
– Use rate controlling drugs if needed
• Check electrolytes, renal function, thyroid function
• May consider cardioversion
• Consider sleep apnea
Referral for Specialty Care
Most elderly
patients with AF/AFl
Rate control/
stroke prevention
Patients who are remain highly
symptomatic despite
rate or rhythm control therapy
Referral to arrhythmia
specialist