Arrhythmias in the elderly Something old, something new?

1. 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

2. 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

3. Aetiology of Arrhythmias by AgeCongenitalorAcquired Younger Middle-aged Brady- or Tachycardias Elderly

4. Congenital Arrhythmias in the Elderly ...?! • 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 - 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

5. Mrs DMcD – Aged 88 yrs 1. Good example of amiodarone’s typical long-term toxicity profile 2. Complicating effect of amiodarone on diagnosis & ablation 3. SVT-ablation’s success is not age dependent • Long history of narrow QRS tachycardias • Infrequent episodes since started amiodarone early 1990s • Became hypothyroid 1998 • Amiodarone discontinued & EP / Ablation recommended • EP-study 1998(shortly after amiodarone withdrawal) – aged 76 yrs • all conduction very sluggish • no inducible arrhythmias & arrhythmia substrate indeterminate (? atrial tachycardia) • EP-repeat study 2010 • Concealed accessory pathway confirmed with AV-reentrant SVT • Ablation of left free wall pathway with single lesion

6. Acquired Arrhythmias Atrial Fibrillation & Ventricular Tachycardia 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)

7. Atrial Fibrillation a degenerative conditon of ‘old age’ (?)

8. Complex patient-pathways in Atrial Fibrillation About 50% patients with AF are diagnosed in 10 care & 20% remain there for management Diagnosis 18% 28% 44% diagnosed in primary care 9% Primary Care A&E/MAU Cardiology Other Spec. 20% remain in primary care 68% referred to cardiology 40% 25% 34% Primary Care Cardiology CoE/GenMed Other Spec. 90% referred to primary care formanagement 65% 26% AF=atrial fibrillation; A&E=accident and emergency; MAU=medical assessment unit; CoE=care of the elderly; GenMed=general medical

9. “Atrial fibrillation begets atrial fibrillation” Sinus Rhythm Evolving Triggers & substrates Eroding anti-AF threshold Cardioversion Paroxysmal AF Persistent AF Permanent AF Secondary electrical changes Secondary structural changes No longer able to restore / maintain SR Secondary electrical changes More frequent / longer episodes

10. When is it pointless to call the fire brigade? Rhythm control management cannot be an afterthought …!

11. Challenge of deploying newer therapies optimallyEquality of access to treatment options..? DDDRP • • 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 • Anti-arrhythmic management • Dronedarone / Vernakalant • Pacing & AV-nodal ablation • Catheter ablation

12. AFFIRM STUDY Inclusion Age > 65 or 1 major risk factor for death or stroke

13. AF – The rhythm versus rate control debate Does this mean sinus rhythm & AF equivalent? NO ! • • Recruited only mildly symptomatic pts, who • could be randomized to either strategy • Success of rhythm control poor with AA Rx • Survival benefits offset by effects of AADs • Spontaneous reversion to SR high

14. ◊ 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 1-2 year follow-up (N = 335) In rhythm control group LV-function compared between SR & AF pts at study end Hagens et al. Heart Rhythm 2005, 2:19-24 ◊ Routine rate control prevents deterioration of LV-function. ◊ Maintenance of sinus rhythm improves LV-function & reduces atrial sizes

15. 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

16. AHA Guidelines 2006Dronedarone & atrial-selective anti-arrhythmic agents (?) Vernakalant (acute cardioversion) Dronedarone

17. 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’)

18. Non-pharmacological therapies for AF in the elderly .....?

19. AHA Guidelines 2006

20. Outcome of AF ablation - randomized comparison of ablation vs drugs Pappone APAF JACC Oct 06

21. NavX-guided point-by-point isolation of pulmonary veins & ‘roof line’ LA & Pulmonary Veins Ablation lesion

22. Radiofrequency catheter ablation of AF in older patients Outcomes & Complications Patients > 75 years: AF < 1 hour +AARx = 82%

23. Selection criteria for catheter ablation of AF • 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) Technically it can be preformed in almost anyone .... but it’s primarily indicated for symptom control not for prognosis!

24. • 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 82 yrs old female presents to A&E

25. 2.4 sec 5.4 sec pause post-AF

26. Low Heart Rate Variability = SSS & AF

27. AF in tachy-brady syndrome likely to be abolished by atrial pacing DDDRP Correct sinus node Ds & restore chronotropic competence + To allow anti-arrhythmic drugs to control tachycardia Atria Ventricles

28. 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

29. Ventricular Tachy-arrhythmias in the elderly

30. A Matter of Life or Death

31. 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 Highly likely to recur! Acute ischaemia / MI Drug induced Biochemical upset ... ‘One-off’ event?

32. 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

33. Commonest cause of VT is old myocardial infarction Progressive LV-dysfunction Renewed coronary ischaemia As well as the arrhythmia recurrences ...

34. If ‘high risk’ of arrhythmia recurrence ... AVID Study AVID Trial (2ndry prevention) ‘ ... Among survivors of VF or sustained VT, causing severe symptoms,the ICD is superior to anti-arrhythmic drugs for increasing overall survival ...’ N Engl J Med 1997, 337:1576-83. P < 0.02

36. 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

37. Mrs WJ - 78 yrs

38. Mrs WJ - 78 yrs ■ Investigations Holter ECGNon-sustained VT (8 bts / 200 bpm) – symptoms (+) EchoLarge anterior LV-akinetic segment (LVEF 34%) Cor angios No obstructive coronary lesions

39. Ms WJ - EP-Testing: Is she capable of sustained VT? 2 extras Sustained VT RV Drive

40. Mrs WJ - 78 yr - VT induce in EP-Lab VT CL = 230ms (260 bpm)

41. 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 with an ICD leads to improved survival compared to conventional medical therapy’ N Engl J Med 1996, 335:1933-40 p = 0.009

42. 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

43. MADIT II Trial Primary Prevention LVEF < 35% & NSVT alone MADIT II Trial (No EP testing) ‘ ... In patients with prior MI & advanced LV-dysfunction, prophylacticICD implantation improves survival and should be considered as a recommended therapy‘ N Engl J Med 2002, 346:877-83 P = 0.007

44. Total Mortality Benefits - NNTT ♥ Combining all trials (10 & 20 prevention; Post MI & DCM) NNTT(1 death in 2 years)= 13 But depends on baseline risk ♥ If primary prevention with post-infarction & LVEF < 30% NNTT(1 death over 2 yrs)= 18 ♥ If same background & inducible VT NNTT(1 death over 2 yrs)= 4 • Most of the benefit .... • Patients with CADs, LV-dysfunction • & inducible VT at EP study • Less benefit ... • Moderate risk group • or CABG or DCM

45. Pacing to improve coordination of cardiac contraction(atrio-ventricular; inter- & intra-ventricular resynchronisation)

46. Pacing to improve LV-function RA LV RVA Electrical resynchronization

47. Cardiac resynchronisation therapy + ICD component 1 CRT & CRTD 3 2

48. 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

49. 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

50. A simple scenario ..? Requires permanent pacing ◊ 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