Atrial Fibrillation Management in Elderly
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ELDERLY AND HEART DISEASE (DE FORMAN AND JM GAZIANO)
Atrial Fibrillation Management in Elderly Wilbert S. Aronow
Published online: 24 July 2012 # Springer Science+Business Media, LLC 2012
Abstract Atrial fibrillation (AF) in older adults is inherently more clinically challenging than sinus rhythm because it is associated with diminished functional capacity and quality of life, as well as higher incidence of mortality, stroke, and coronary events. AF with a rapid ventricular rate is particularly likely to cause demand ischemia, heart failure with preserved ejection fraction (HFPEF), as well as tachycardia-related cardiomyopathy. Indications for directcurrent cardioversion, pharmacological cardioversion, rate control, and nondrug therapies are discussed. Differences in clinical outcome based on ventricular rate control versus drug treatment to maintain sinus rhythm are also reviewed. Indications for anticoagulation for chronic or paroxysmal AF are included, including long-term warfarin and direct thrombin inhibitors (dabigatran, rivaroxaban, or apixaban) and/or aspirin. Keywords Atrial fibrillation . Thromboembolism . Anticoagulant therapy . Aspirin . Warfarin . Dabigatran . Rivaroxaban . Apixaban . Beta blockers . Clopidogrel . Cardioversion . Antiarrhythmic drugs . Ventricular rate control . Radiofrequency catheter ablation . Pacemakers
Prevalence of atrial fibrillation increases significantly with advanced aging. Management complexity also increases. While the arrhythmia is more likely to produce symptoms
W. S. Aronow Westchester Medical Center/New York Medical College, Valhalla, NY, USA W. S. Aronow Cardiology Division, Department of Medicine, New York Medical College, Valhalla, NY, USA W. S. Aronow (*) Cardiology Division, New York Medical College, Macy Pavilion, Room 138, Valhalla, NY 10595, USA e-mail: [email protected]
and instability, treatments are also more likely to lead to untoward consequences. In this review, we will provide a brief overview of the pathophysiology and management of this common problem.
Treatment of Underlying Causes Atrial fibrillation (AF) in older adults usually arises in the context of clinical stressors. Both non-cardiac and cardiac triggers can trigger AF. Congestive heart failure, hyperthyroidism, infection, hypoglycemia or pulmonary embolism are all common precipitants that must be addressed as management priorities. Similarly, hypokalemia, hypovolemia, and hypoxia must be treated. Alcohol, coffee, and medications (particularly sympathomimetics) are also common precipitants to the arrhythmia that must be considered and avoided. If mitral valve disease is a likely precipitant, surgery is an important consideration for those patients who are candidates for mechanical interventions. Elective cardioversion for AF in patients with structural valvular disease who are not candidates for repair is rarely successful; even if AF is converted to sinus rhythm, early relapses are common. Therapy in these instances should be shifted to rate control and anticoagulation. Patients with parox
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