Objectives The prevalence of atrial fibrillation (AF) and atrial flutter (AFl) increases with age. Prior research suggests that underprescription of anticoagulants, such as warfarin, in older adults can lead to increased morbidity and mortality. We analyzed rates and patterns of warfarin prescription in older adults. Methods In this prospective observational study, we enrolled 2179 consecutive patients with admission diagnosis of AF or AFl. Those placed on a non-warfarin anticoagulation (189 patients) were excluded. Patients were then divided into “older cohort” (≥75 years of age) and “younger cohort” (<75 years of age). Within the older cohort, prescription patterns of warfarin were analyzed. Serial prospective follow-up was 3.1±2.06 years. Results Of the 1990 patients, 46.9% were ≥75 years older, of which 51.1% were prescribed warfarin. There was no difference between mean CHA2DS2-VASc score and warfarin prescription (OR=1.06 (95% CI 0.93–1.21), p=0.388) in the older cohort. After adjusting for hypertension, glomerular filtration rate, and Black race, appropriate warfarin prescription in older adults was independently associated with lower aspirin prescription rates (OR=0.57 (95% CI 0.43–0.75), p<0.001), lower body mass index (OR=1.03 (95% CI 1.01–10.6), p=0.018), and lower hemoglobin levels (OR=1.11 (95% CI 1.04–1.19), p=0.002). Conclusions In our study, adults 75 years and older with AF and AFl tended to have lower rates of warfarin prescription despite higher CHA2DS2-VASc score and higher risk of thromboembolic events. Anemia, lower weight, and aspirin use were characteristics associated with warfarin underprescription. These patterns can shed light on clinicians' perceived hesitancy to anticoagulate certain older adults. Funding Acknowledgement Type of funding sources: None.
Introduction: Implantable Loop Recorders (ILR) are used in detecting and monitoring arrhythmias. These subcutaneous devices remain in place for years for continuous cardiac monitoring. There have been few studies on how best to position an ILR for maximum accuracy and comfort. Currently, manufacturers recommend insertion of the ILR at a 45-degree angle from the sternum at the 4th intercostal space and a minimum R wave amplitude of 0.2mV for adequate sensing. We adopted the technique of implanting all ILRs horizontally between the 4th and 5th ribs and examined patient outcomes. Methods: Data was obtained through chart review of 288 patients who received a horizontally placed ILR from 2019 to 2021. Patient’s age, sex, BMI, indication for ILR, ILR manufacturer, episodes of artifact and complications were collected. The R wave magnitude (mV) immediately succeeding implantation was recorded from the procedure note. Results: Of our patients, 91% received a Medtronic ILR, 6% had a Boston Scientific ILR and 3% had a Biotronik ILR. The mean age was 60 ± 14 years, with 51% of patients being male. Within the sample, 27% had a BMI less than 25 kg/m 2 , 33% were overweight, and 40% were obese. Approximately 271 patients had a documented R wave amplitude at implantation, with the average being 0.44 mV ± 0.41 (95% CI 0.39 to 0.48). Of 240 patients with follow-up, 8% had an arrhythmia recorded that was found to be a false positive episode. There were no major complications. Conclusions: Using the horizontal approach, we obtained adequate sensing based on average R wave amplitude. We had very few false positive arrhythmias, as only 8% of our patients were noted to have a false positive reading versus 25% reported in other studies. This approach minimizes involvement of breast tissue and thus reduces risk of peri-procedural bleeding and ILR migration and increases patient comfort. The outcomes of our population indicate that this is a viable approach and may be superior to standard.
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