10th AGM, BGS Cardiovascular Section, London - July ‘10
Arrhythmias in the elderly
Something old, something new?
John P. Bourke
Consultant & Senior Lecturer in Cardiology
Freeman Hospital
Arrhythmias in the elderly
◊ Changing aetiology of arrhythmias with age
◊ Congenital arrhythmias still present ....
◊ Update on atrial fibrillation management
◊ Ventricular tachy-arrhythmias in the elderly
◊ Device therapy dilemmas in the elderly
Aetiology of Arrhythmias by Age
Congenital or Acquired
Younger
Middle-aged
Brady- or Tachycardias
Elderly
Congenital Arrhythmias in the Elderly ...?!
• Those that have been putting up with SVTs for years
• Increasing SVT frequency due to increased ectopy despite drugs
• Emergence of pre-excitation due to AV-nodal disease or medications
•
•
•
•
Catheter ablation equally applicable with 95% success rates
SVT with BBB commoner & may complicate diagnosis
AV-nodal modification (AVJRT) carries higher risk of AV-block
WPW as bystander to acquired atrial tachy-arrhythmias
– SVT stops with CSM / Adenosine is the key to Dx –
- SVT returns > 2 yrs after successful ablation = different arrhythmia -
Mrs DMcD – Aged 88 yrs
• Long history of narrow QRS tachycardias
1.
Good example
of amiodarone’s
long-term
toxicity profile
• Infrequent
episodes
since started typical
amiodarone
early 1990s
– Became hypothyroid 1998
– Amiodarone discontinued & EP / Ablation recommended
2. Complicating effect of amiodarone on diagnosis & ablation
• EP-study 1998 (shortly after amiodarone withdrawal) – aged 76 yrs
– all conduction very sluggish
– no inducible arrhythmias & arrhythmia substrate indeterminate (? atrial tachycardia)
3. SVT-ablation’s success is not age dependent
• EP-repeat study 2010
– Concealed accessory pathway confirmed with AV-reentrant SVT
– Ablation of left free wall pathway with single lesion
Acquired Arrhythmias
10 Electrical
- Age-related AF / A-flutter
- Tachy-brady syndrome (Sinus node Ds)
20 to Structural Disease
- Hypertensive heart Ds
- Post-infarction / Cardiomyopathy
- Valve disease (eg: MR or AR)
Atrial Fibrillation & Ventricular Tachycardia
Atrial Fibrillation
a degenerative conditon of ‘old age’ (?)
Complex patient-pathways in Atrial Fibrillation
About 50% patients with AF are diagnosed in 10 care
& 20% remain there for management
44% diagnosed
in primary care
Primary Care
20%
remain in
primary
care
28%
Diagnosis
9%
A&E/MAU
Cardiology
18%
Other Spec.
68%
referred to
cardiology
40%
Primary Care
25%
34%
Cardiology
90%
referred to
primary
care for
management
CoE/GenMed
Other Spec.
65%
26%
AF=atrial fibrillation; A&E=accident and emergency; MAU=medical assessment unit; CoE=care of the elderly; GenMed=general medical
“Atrial fibrillation begets atrial fibrillation”
Sinus Rhythm
Eroding anti-AF
threshold
Paroxysmal
AF
Evolving
Triggers &
substrates
Cardioversion
Persistent
AF
Secondary electrical changes
More frequent / longer episodes
Permanent
AF
Secondary electrical changes
Secondary structural changes
No longer able to restore / maintain SR
When is it pointless to call the fire brigade?
Rhythm control
management
cannot be an
afterthought …!
Challenge of deploying newer therapies optimally
Equality of access to treatment options..?
• Anti-arrhythmic management
– Dronedarone / Vernakalant
– Pacing & AV-nodal ablation
– Catheter ablation
• Stroke Prevention
- Warfarin vs Dabigatran
- Left atrial occlusion devices
• Newer options in valve disease
- Mitral valve clips for MR
- TAVI for AS
- Timing of surgical MVR
DDDRP
AFFIRM
STUDY
Inclusion
Age > 65
or
1 major risk
factor for
death or stroke
AF – The rhythm versus rate control debate
% pts in SR at study end
Does this mean
sinus rhythm & AF equivalent?
62.6
NO !
34.6
38.7
38
rhythm control
rate control
• Recruited only mildly symptomatic pts, who
could be randomized to either strategy
•Success of rhythm control poor with AA Rx
10
9
RACE
STAF
• Survival benefits offset by effects of AADs
• Spontaneous reversion to SR high
AFFIRM
◊ Presence of AF was associated with worse NYHA-FC (p < 0.0001)
◊ Improved in 6-minute walk test in rhythm control group (p = 0.049)
Effect of rate & rhythm control on left ventricular function & cardiac
dimensions in patients with persistent atrial fibrillation: RACE
Study
Echo study
with deterioration
1-2 year follow-up
(N = 335)
◊ Routine rate control
prevents
of LV-function.
In rhythm control group LV-function compared between SR & AF pts at study end
◊ Maintenance of sinus rhythm improves LV-function & reduces atrial sizes
Hagens et al. Heart Rhythm 2005, 2:19-24
Circulation 2004, 109:1509-15
◊ Variables associated with increased risk of death
- Increasing age
- Coronary artery disease
- Congestive cardiac failure; Left ventricular dysfunction
- Diabetes mellitus or smoking
- Stroke or TIA
- Mitral regurgitation
◊ Variables associated with reduced risk of death
- Maintenance or sinus rhythm
- Warfarin therapy
◊ Anti-arrhythmic drugs ≠ improved survival
- any benefits are offset by adverse effects
AHA Guidelines 2006
Dronedarone & atrial-selective anti-arrhythmic agents (?)
Dronedarone
Vernakalant
(acute cardioversion)
Atrially-selective anti-arrhythmic agent(s)
Vernakalant
•
Atrially-selective potassium channel blocker with short half life
•
Reduced risk of pro-arrhythmia & negative inotropic effects
•
Currently an iv drug for acute cardioversion of recent onset AF
•
Oral version likely to follow for maintenance of SR
May reduce the threshold for attempted cardioversion
in borderline cases
(no GA or sedation required; ‘less inconvenient’)
Non-pharmacological therapies
for AF in the elderly .....?
AHA Guidelines 2006
Outcome of AF ablation - randomized comparison of ablation vs drugs
Pappone APAF JACC Oct 06
NavX-guided point-by-point
isolation of pulmonary veins &
‘roof line’
LA & Pulmonary Veins
Ablation lesion
Radiofrequency catheter ablation of AF in older patients
Outcomes & Complications
N = 240
< 65 years
65-75 years
> 75 years
p
91
88
61
---
Persistent AF
24%
34%
66%*
< 0.01
Major complications
1%
1%
0%
NS
Minor complications
4%
5%
5%
NS
SR without AARx
94%*
84%
61%
< 0.01
Hospital attendances
Pre- vs Post-ablation
22 / 3
26 / 4
20 / 2
< 0.01
N
Patients > 75 years: AF < 1 hour + AARx = 82%
Selection criteria for catheter ablation of AF
• Technically it can be preformed in almost anyone .... but it’s primarily
indicated for symptom control not for prognosis!
• Best results - No structural heart disease & paroxysmal AF
Serious complications = 1-2% per procedure
Success = 85% with 1-2 procedures
• Less predictable results – persistent AF & dilated LA / LVH
Success = 70% with 1-2 procedures
• Research procedures – paroxysmal or persistent AF in
CCF / HCM or chronic persistent AF (> 12 mths)
82 yrs old female presents to A&E
•
Sustained palpitations for several hours
Anxious but stable; ECG confirms AF; ventricular rate = 110 / min
She is on no cardio-active medications
•
Increasingly frequent similar episodes x 14 months, lasting < 4 hours
Episodes tend to start when she is at rest or even asleep.
•
Recently, feels faint as palpitations terminate with two falls resulting
2.4 sec
5.4 sec pause post-AF
Low Heart Rate Variability = SSS & AF
AF in tachy-brady syndrome likely
to be abolished by atrial pacing
Atria
Correct sinus node Ds & restore
chronotropic competence
+
DDDRP
Ventricles
To allow anti-arrhythmic drugs to
control tachycardia
Arrhythmias in the elderly
◊ Changing aetiology of arrhythmias with age
◊ Congenital arrhythmias still present ....
◊ Update on atrial fibrillation management
◊ Ventricular tachy-arrhythmias in the elderly
◊ Device therapy dilemmas in the elderly
Ventricular Tachy-arrhythmias
in the elderly
A Matter of
Life or Death
The same arrhythmia – very different management ... !?
1.
Why did it happen ?
2.
Will it recur ?
3.
Does it require post-acute management ?
4.
Does it require specific anti-arrhythmic management ?
Remote MI
Poor LV function
Acute ischaemia / MI
Drug induced
Biochemical upset
Highly likely to recur!
... ‘One-off’ event?
Commonest cause of VT is old myocardial infarction
■ 72 yr old male
■ PHx: inferior MI (1989)
■ CABG x 4 (1990)
■ LVEF = 32%
■ Rx: bisoprolol, ramipril, simvastatin, aspirin
Commonest cause of VT is old myocardial infarction
Progressive LV-dysfunction
Renewed coronary ischaemia
As well as the arrhythmia recurrences ...
If ‘high risk’ of arrhythmia recurrence ...
AVID Study
AVID Trial (2ndry prevention)
‘ ... Among survivors of VF or
sustained VT, causing severe
P < 0.02
symptoms, the ICD is superior to
anti-arrhythmic drugs for increasing
overall survival ...’
N Engl J Med 1997, 337:1576-83.
Mrs WJ - 78 yrs
■ Jan ‘10:
OPD referral - ‘Palpitations’ / No LOC or compromise
- Uncomplicated anterior MI (2008)
- Examination: No abnormalities
- Hx suggestive of isolated ectopic beats
■ Other:
ACEi, BB, statin & aspirin therapy
Ex-smoker (10 / day)
Normotensive
No DM
Mrs WJ - 78 yrs
Mrs WJ - 78 yrs
■ Investigations
Holter ECG
Non-sustained VT (8 bts / 200 bpm) – symptoms (+)
Echo
Large anterior LV-akinetic segment (LVEF 34%)
Cor angios
No obstructive coronary lesions
Ms WJ - EP-Testing: Is she capable of sustained VT?
2 extras
Sustained VT
RV Drive
Mrs WJ - 78 yr - VT induce in EP-Lab
VT CL = 230ms (260 bpm)
MADIT I Trial
Primary Prevention
LVEF < 35% & NSVT & inducible VT
MADIT I Trial
EP-testing(+)
‘ ... In patients with prior MI, who are at
high risk of VT / VF, prophylactic therapy
p = 0.009
with an ICD leads to improved survival
compared to conventional medical
therapy’
N Engl J Med 1996, 335:1933-40
Mr RL - 80 yrs
■ Aug ‘09:
Admitted to DGH after collapse & spontaneous recovery
Also several previous ‘dizzy spells’
■ PHx:
Ischaemic heart Ds
Previous anterior MI
LBBB on ECG (QRS = 120 ms)
LVEF < 30%
■ Rx: lisinopril, metoprolol, furosemide, L-thyroxine, allopurinol
MADIT II Trial
Primary Prevention
LVEF < 35% & NSVT alone
MADIT II Trial
(No EP testing)
‘ ... In patients with prior MI &
advanced LV-dysfunction,
P = 0.007
prophylactic ICD implantation
improves survival and should be
considered as a recommended
therapy‘
N Engl J Med 2002, 346:877-83
Total Mortality Benefits - NNTT
♥ Combining all trials (10 & 20 prevention; Post MI & DCM)
(1 death
Most of theNNTT
benefit
.... in 2 years)
= 13
Patients with CADs, LV-dysfunction
& inducible
VT at risk
EP study
But depends
on baseline
♥Less
If primary
prevention
benefit
... with post-infarction & LVEF < 30%
NNTT (1 death over 2 yrs)
Moderate risk group
or CABG or DCM
= 18
♥ If same background & inducible VT
NNTT (1 death over 2 yrs)
= 4
Pacing to improve coordination of cardiac contraction
(atrio-ventricular; inter- & intra-ventricular resynchronisation)
Pacing to improve LV-function
RA
LV
RVA
Electrical
resynchronization
Cardiac resynchronisation therapy
+ ICD component
1
CRT
&
CRTD
3
2
MADIT-CRT Trial
To assess whether CRT-D reduces mortality &
heart failure events in patients with:
NYHA class I-II
QRS > 130ms
LVEF < 30%
■ 34% reduced all-cause mortality
or 1st heart failure event with CRT-D
(p < 0.001)
■ 41% reduction in HF events
(p < 0.001)
■ Benefits IHD = DCM
p < 0.001
Arrhythmias in the elderly
◊ Changing aetiology of arrhythmias with age
◊ Congenital arrhythmias still present ....
◊ Update on atrial fibrillation management
◊ Ventricular tachy-arrhythmias in the elderly
◊ Device therapy dilemmas in the elderly
A simple scenario ..?
◊ 79 yr old lady referred with symptomatic CHB of recent onset
◊ Asymptomatic coronary Ds (ie: no active ischaemia) & previous LBBB
◊ Old inferior MI, LVEF 25% & NYHA II dyspnoea
◊ Recent drug therapy: ACEi, Beta-blocker, Statin, Aspirin & Furosemide
Requires permanent pacing
Made unnecessarily complex ....???
What is her most appropriate therapy?
Standard
Pacemaker
(2-leads)
Resynchronisation
Pacemaker
(3-leads)
Combined Resynchronisation
Pacing & Defibrillator
Arrhythmias in the elderly
◊ Changing aetiology of arrhythmias with age
◊ Congenital arrhythmias still present ....
◊ Update on atrial fibrillation management
◊ Device therapy dilemmas in the elderly