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Management of A trial Fibrillation in older patients

Management of A trial Fibrillation in older patients. Debra Bynum, MD Associate Professor of Medicine Division of Geriatric Medicine. Classification of Atrial Fibrillation. Recurrent: 2 or more episodes Paroxysmal: recurrent atrial fibrillaiton that terminates spontaneously

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Management of A trial Fibrillation in older patients

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  1. Management of Atrial Fibrillation in older patients Debra Bynum, MD Associate Professor of Medicine Division of Geriatric Medicine

  2. Classification of Atrial Fibrillation • Recurrent: 2 or more episodes • Paroxysmal: recurrent atrialfibrillaiton that terminates spontaneously • Persistent: a fib more than 7 days • Long Standing afib: greater than one year • Permanent afib: longstanding afib in which cardioversion has failed or not attempted

  3. Secondary AF • Causes • Acute MI • Cardiac surgery • Pericarditis • Myocarditis • Hyperthyroidism • PE • Pneumonia • Concurrence • AF and secondary causes are both common and may be true, true and unrelated….

  4. Lone AF • Younger (under 60) • No clinical cardiac disease • No HTN • Normal echo • Otherwise normal EKG • Good prognosis • 12-30% of total cases of AF are Lone AF

  5. Nonvalvular AF • Absence of rheumatic mitral valve disease, prosthetic heart valve or mitral valve repair • Often carries less risk of thromboembolism

  6. Prevalence as a Geriatric Disease • General population: 0.4% -1 % • 8 % in those older than 80 • Median age: 75 • 70% of all patients with AF are between 65-85 • Increased in patients with underlying CHF

  7. Stroke Risk • Overall: 2-7% /year • 1 of every 6 strokes occur in patients with AF • Impact of age: • Annual risk of stroke from Framingham data • 50-59 year olds: 1.5 %/year • 80-89 year olds: over 10% /year

  8. Assessing Stroke Risk • CHADS2 • CHF • HTN • Age over 75 • Diabetes • Stroke or TIA(2 points)

  9. CHADS2 and Adjusted Stroke

  10. CHADS2 and anticoagulation recommendations • 0= aspirin • 1 or 2= either warfarin or ASA (see next slide) • 3 or more: warfarin

  11. AHA guidelines for antithrombotic therapy with AF Circulation 2006

  12. Warfarin • 5 large RCTs in early 1990s for prevention of thromboembolism in patients with nonvalvular AF • Overall 60% reduction in risk of stroke after 1-2 year follow up • INR 2-3 ideal • Average age of patients: 69 • Caveat: Patient age and intensity of anticoagulation are most important predictors of bleeding

  13. Aspirin • Better than nothing but not as good as warfarin

  14. Aspirin and Clopidogrel • ACTIVE trial, NEJM May 2009 • Clopidogrel and ASA with AF better than ASA alone, but higher risk of bleeding

  15. Efficacy of anticoagulation (OAC) at preventing stroke (pooled data from RCTs) OAC vs control: 2-3% /year vs 6-8%/year ASA vs control: 5 %/year vs 6%/year OAC vs ASA: 2-3%/year vs 5%/year OAC vs nothing: 68% RRR ASA vs nothing: 21% RRR OAC vs ASA: 52% RRR

  16. Risk of Bleeding • Major bleeding in pooled data from RCTs = 1.2 %/year • Increased bleeding with increased age and higher INR • ICH: 0.5%/year on OAC (one study with older patients and INR closer to 4 had ICH rates of 1.8%/year) • Goal INR in older patients: 2-3

  17. Weighing Risks and Benefits • Care with applying data to frail elders who would have been excluded from trials • But more often we still overly estimate risk and underestimate benefit • Survey of Cardiologist registry of patients with AF: • 70-80% patients at high risk of CVA (CHADS2 over 2) received warfarin • >40% with CHADS 2 of 0 received warfarin!

  18. Rate vs Rhythm Control • “It is well known that atrial fibrillation is associated with a number of clinical problems, including death, thromboembolism(primarily stroke), heart failure, and other morbidity and symptoms. However, association does not prove cause and effect… An apparently widely held view is that if atrial fibrillation can be abolished, the problems associated with atrial fibrillation would be abolished... Such thinking ignores the probability that these clinical problems are at least partly caused by the disease process causing atrial fibrillation…. • Dr. George Wyse

  19. Rate vs Rhythm Summary • 5 RCTs, over 5000 patients studied • NO difference in outcomes • Death, stroke, QOL all same • Slight increase in ADEs and hospitalizations in Rhythm control group • AFFIRM: maybe slightly better outcomes with rhythm control in patients with severe LV dysfunction

  20. Strict vs Lenient Rate Control (April 2010 NEJM) • 600 + patients, RCT • Lenient control: Target resting HR <110 • Strict control: resting target HR <80 and exercise target HR <110

  21. Patients reaching Target

  22. Overall Results • No difference in combined events • No difference in hospitalizations or CHF • Death: 5.6% in lenient group vs 6.6% strict group (nonsignificant) • BUT fewer in strict control group achieved target HR

  23. Summary • AF common and associated with mortality, hospitalizations, CHF, stroke • Many studies exclude older patients • Consider individual risk for each patient– we tend to overestimate risk and underestimate benefit • Use CHADS2 and guidelines to help determine use of anticoagulation • Rate control is as good as rhythm control • Moderate rate control is likely as good as attempts at more strict rate control

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