From left bundle branch block to Icelandic whales: the multiple perils of atrial fibrillation management in the elderly.

We present the case of an elderly woman which demonstrates how AF therapy in aged individuals is particularly challenging for the presence of complex conditions. The rhythm- or the rate control strategy must be carefully chosen based on individual risk profile. Oral anticoagulant therapy must be wisely managed to maximize benefits-in terms of stroke and dementia control-and to reduce complications.

Atrial fibrillation after electrical cardioversion in elderly patients: a role for arterial stiffness? Results from a preliminary study.

BACKGROUND AND AIMS: Atrial fibrillation (AF) is the most frequent arrhythmia of the elderly, and electrical cardioversion (ECV) is a common procedure, although incidence of recurrences remains high. We evaluated the possible association between arterial stiffness (AS) and the persistence or recurrence of AF in elderly patients after ECV. METHODS: We enrolled all subjects undergoing ECV over a 9-month period. AS was evaluated with the cardio-ankle vascular index (CAVI). Patients were then visited at follow-up (on average at 6 months). RESULTS: Thirty-one patients (age 78 ± 7 years; men 67.7 %; CHA2DS2-VASc 4.1 ± 1.6; AF length >2 months 51.6 %; CAVI 9.9 ± 1.6) underwent ECV. At follow-up, sinus rhythm was recorded in 16 (51.6 %) patients. At multivariate analysis, the presence of AF was directly associated with CHA2DS2-VASc score and CAVI. Amiodarone therapy reduced the risk of relapsed AF. CONCLUSIONS: In elderly AF patients treated with ECV, AS at baseline seems to predict AF at follow-up.

Psychological effects of treatment with new oral anticoagulants in elderly patients with atrial fibrillation: a preliminary report.

BACKGROUND AND AIMS: Atrial fibrillation (AF) is the most common arrhythmia in elderly people, yet oral anticoagulation is underused in the aged. We tried to determine whether new oral anticoagulants (NOA) have greater psychological tolerability than warfarin. METHODS: Age-, gender-matched groups of AF patients receiving NOA (N = 15) or warfarin (N = 15) were assessed with the Anti-Clot Treatment Scale (ACTS) and the Perceived Stress Scale (PSS). RESULTS: Patients were old (81 ± 9 years). NOA group showed greater psychological satisfaction, with lower therapy-related burden (ACTS burdens: 16.3 ± 4.5 vs. 32.9 ± 10.2, p < 0.001) and higher awareness of benefits (ACTS benefits: 13.0 ± 1.3 vs. 10.8 ± 1.9, p = 0.001). Even stress was lower (PSS: 13.1 ± 4.0 vs. 17.1 ± 4.2, p = 0.013). The multivariate analysis confirmed these findings, showing that higher levels of anxiety and depression could justify more stress in warfarin patients. CONCLUSIONS: The results of this preliminary study show that NOA have an improved psychological impact compared with warfarin in elderly patients.

Age, left atrial dimension and arterial stiffness after external cardioversion of atrial fibrillation. A vascular component in arrhythmia maintenance? Results from a preliminary study.

BACKGROUND AND AIMS: Atrial fibrillation (AF) is the most frequent arrhythmia in elderly patients. Aims of this study were to evaluate the predictors of arterial stiffness after external cardioversion (ECV) of AF and to establish whether a link exists between vascular properties and left atrial diameter (LAD). METHODS: We studied 33 patients (age 73 ± 12 years). After 5 h from ECV of persistent AF, an echocardiogram was recorded and arterial stiffness was evaluated with cardio-ankle vascular stiffness index (CAVI). RESULTS: In multivariate analysis (R = 0.538, p = 0.006), CAVI (mean 9.60 ± 1.63) increased with age (p = 0.018) and with an AF length ≤3 months (p = 0.022). LAD was significantly related to CAVI (p = 0.007) even after adjustment for interventricular septum thickness (p = 0.018) (R = 0.574, p = 0.002). CONCLUSIONS: In patients with AF, immediately after ECV, arterial stiffness is associated with age and AF length, and could represent an important factor for left atrium remodeling and, therefore, for AF maintenance.

Management and prognosis of atrial fibrillation in diabetic patients: an EORP-AF General Pilot Registry report.

Aims: Diabetes mellitus (DM) is one of the most important cardiovascular risk factors. The aim of this study was to evaluate clinical correlates of DM, including management and outcomes, in the EURObservational Research Programme (EORP)-Atrial Fibrillation (AF) General Pilot (EORP-AF) Registry of the European Society of Cardiology. Methods and results: We studied consecutive patients (N = 3101) enrolled in 70 centres of nine European countries between February 2012 and March 2013, and compared diabetics with non-diabetics during a 1-year follow-up. In the overall cohort, the prevalence of DM was 20.6%. Diabetics were older (71 ± 9 vs. 68 ± 12 years, P < 0.0001) and had more comorbidities, higher CHA2DS2-VASc score (4.6 ± 1.6 vs. 2.9 ± 1.7, P < 0.0001) and higher prevalence of permanent AF (21.5 vs. 16.0%, P = 0.0022). Quality of life amongst DM patients was significantly worse [atrial fibrillation quality of life questionnaire (AF-QoL) score 45.2 ± 19.2 vs. 49.3 ± 20.1, P < 0.0001]. Amongst diabetics, the use of electrical cardioversion (16.2 vs. 24.6%, P < 0.0001) and catheter ablation (3.3 vs. 8.6%, P < 0.0001) was lower, whilst oral anticoagulants were more often prescribed (84.3 vs. 78.9%, P = 0.0027). After one year, diabetic patients had significantly higher all-cause (11.9 vs. 4.9%, P < 0.0001), cardiovascular (6.2 vs. 1.9%, P < 0.0001), and non-cardiovascular mortality (2.3 vs. 1.1%, P = 0.0356). Conclusion: In AF patients, DM is associated with a higher prevalence of comorbidities and a worse quality of life. After one year, all-cause, cardiovascular, and non-cardiovascular mortality were significantly higher in diabetic subjects.

Age-Related Differences in Presentation, Treatment, and Outcome of Patients With Atrial Fibrillation in Europe: The EORP-AF General Pilot Registry (EURObservational Research Programme-Atrial Fibrillation).

OBJECTIVES: This study sought to compare age-related differences in presentation, treatment, and outcome of atrial fibrillation (AF) in a wide cohort of European subjects. BACKGROUND: AF is the most common sustained arrhythmia in the elderly. METHODS: We evaluated all patients enrolled in the EORP-AF (EURObservational Research Programme-Atrial Fibrillation) General Pilot Registry in 70 centers of 9 European countries. RESULTS: Among 3,119 subjects, 1,051 (33.7%) were age ≥75 years. Permanent AF was significantly more common in the elderly, who had a higher prevalence of hypertension, valvular diseases, chronic heart failure, coronary artery disease, renal failure, chronic obstructive pulmonary disease, and prior hemorrhagic event or a transient ischemic attack. Common diagnostic tests were underused in older subjects. Despite their higher stroke risk, the use of oral anticoagulants was significantly lower in the elderly (76.7% vs. 82.8%; p = 0.0012), whereas aspirin and clopidogrel alone or in combination were more often prescribed. Rate control was the management of choice in the older group, with electrical cardioversion and catheter ablation performed less frequently than in the younger age group. Antiarrhythmic drugs were significantly less prescribed in the elderly (29.8% vs. 41.7%; p < 0.0001). At the 1-year follow-up, mortality (11.5% vs. 3.7%; p < 0.0001) and the composite of stroke/transient ischemic attack, systemic thromboembolism, and/or death (13.6% vs. 4.9%; p < 0.0001) were significantly higher in the ≥75 years of age cohort. CONCLUSIONS: In older patients, AF is more often associated with comorbidities. Rate control is the preferred therapeutic approach. Despite a higher CHA2DS2-VASc score, the use of oral anticoagulation is suboptimal. In elderly subjects, the rate of adverse events is higher at follow-up.

External Cardioversion of Atrial Fibrillation Causes an Early Improvement of Cardiac Performance: A Longitudinal Strain Analysis Study.

INTRODUCTION: Atrial fibrillation (AF) is often associated with heart failure. Several studies have demonstrated that resumption of sinus rhythm (SR) improves cardiac output in the long-term. Aims of this study were to evaluate the acute variations of left ventricular (LV) performance, following successful external cardioversion (ECV) of persistent AF using longitudinal strain (LSt) analysis, and the influence of inflammation. MATERIALS AND METHODS: We enrolled 48 patients with AF (age: 73 ± 12 years, men: 83.3%). A standard transthoracic echocardiographic evaluation was performed before the procedure and 6 h later; this included the analysis of LV endocardial peak LSt, a measure of myocardial deformation. In the last 32 patients, plasma concentration of interleukin-6 (IL-6) was also determined. RESULTS: Restoration of SR led to the decrease of heart rate (HR) (74 ± 21 vs 64 ± 10 bpm, P < 0.001) and LV end-systolic volume (30 ± 16 vs 27 ± 17 mL/m2, P = 0.001), and to the increase of LV end-diastolic volume (LVEDV) (56 ± 20 vs 60 ± 21 mL/m2, P = 0.036) and ejection fraction (EF) (48 ± 10 vs 57 ± 11%, P < 0.001). Peak LSt improved in 43 (89.6%) patients (-12.9 ± 3.3 vs -18.0 ± 4.7%, P < 0.001). Multivariate analysis (R = 0.729, P < 0.001) showed that strain changes were directly correlated with basal HR and the appearance of atrial mechanical activity and inversely correlated with corrected thyroid dysfunction, LVEDV and the presence of a permanent pacemaker. Higher levels of IL-6 negatively affected LV performance improvement. CONCLUSIONS: Effective ECV of AF determines a significant and fast improvement of LV performance, which is readily captured by LSt analysis. Inflammatory status may impact the response to SR restoration.

[Use of devices in elderly patients with chronic heart failure]. / I dispositivi negli anziani con scompenso cardiaco cronico.

Chronic heart failure (CHF) is a frequent and clinically relevant condition in elderly patients. Despite the improvements in medical therapy, CHF mortality is persistently high. The introduction into clinical practice of pacemakers for cardiac resynchronization therapy (CRT) and of implantable cardioverter-defibrillators (ICD) has significantly increased survival in CHF patients. In spite of clinical and epidemiological data, evidence of the effectiveness of these devices in the elderly is scant, and the few existing data derive from observational studies. Regarding CRT, in 1787 patients, the InSync/InSync ICD study showed no age-related differences in the prevalence of responders to therapy (about 60%) and in procedural complication rates (11%). Regarding ICD, in the 6311 patients enrolled in the Italian Clinical Service Project, 22.6% of the excess mortality observed in older subjects was due to comorbid conditions. Specific controlled clinical trials are needed to address the impact of CRT and ICD on health-related quality of life, disability and cognitive profile. The findings obtained will be useful to clarify clinical, ethical and cost-effectiveness issues in order to develop specific age-oriented guideline recommendations.