Introduction Atrial fibrillation (AF) is the most common arrhythmia and its incidence rises with age. Especially geriatric patients are at high risk for the development of AF as well as its complications. These high risk patients might benefit the most of oral anticoagulation. AF is however often asymptomatic in these patients and might stay undiagnosed. Purpose To assess the outcomes of opportunistic screening on AF on a geriatric outpatient clinic with a hand held single lead ECG device. Methods All consecutive patients 60 years and older that visited the outpatient clinic between the 1st of June 2017 and the 1st of June 2018 were eligible. Patients who were not able or willing to give informed consent, or had a pacemaker (PM) or internal cardioverter defibrillator (ICD) were excluded. Patients were screened 2 or 3 times at every visit with the MyDiagnostick©, a hand held single lead ECG device with inbuilt algorithm that identifies AF [1]. At baseline all patients underwent a comprehensive geriatric assessment (CGA), including a 12 lead ECG, physical, cognitive and functional assessment and medication review. All baseline ECGs were reviewed by 1 cardiologist and all measurements with the single lead device were reviewed by 2 independent cardiologists. Disagreement about the rhythm on the measurements was resolved by discussion between the cardiologists. Results 498 consecutive patients were eligible for inclusion. We excluded 39 patients: 20 patients had a PM or ICD, 17 did not want to participate and of 2 the medical files were incomplete. A total of 459 patients participated in this study. The mean age was 78±7.3 years and ranged from 60 to 100 years, 245 patients (53%) were female. Patients were known with 5±3 morbidities and used 6±4 different drugs. At baseline 88 (19%) patients were known with AF and AF was first diagnosed in 24 (5%) patients, constituting to an overall prevalence of 23% within this ambulatory geriatric population. Of these 24 patients, 4 (1%) showed AF on their baseline ECG and in 20 (4%) patients AF was found using the handheld device. A total of 1345 measurement with the handheld device were performed, 14 measurements (1%) were of too low quality to use, 32 (2%) were of poor quality, 148 (11%) acceptable and 1151 (86%) were of good quality. Sensitivity of the hand held device for detecting AF is 83.9%, specificity 99.2%, negative predictive value 99.6%, and positive predictive value 72.2%. Conclusions Opportunistic screening for AF with a hand held ECG device has a 5 times higher yield than the standard CGA with an 12 lead ECG at the first visit only. Also, AF can be reliably excluded after a negative measurement. Because of the potential benefit of OAC we advocate screening geriatric patients for AF at every doctor's visit. However, considering the positive predictive value, a confirmatory ECG remains necessary to confirm the diagnosis of AF. Acknowledgement/Funding None

Aims Screening for atrial fibrillation (AF) is recommended by the European Society of Cardiology guideline to prevent strokes. Cost-effectiveness analyses of different screening programs for AF are difficult to compare, because of varying settings and models used. We compared the impact and cost-effectiveness of various AF screening programs in the Netherlands. Methods and results The base case economic analysis was conducted from the societal perspective. Health effects and costs were analysed using a Markov model. The main model inputs were derived from the ARISTOTLE, RE-LY and ROCKET AF trial combined with Dutch observational data. Univariate, probabilistic sensitivity and various scenario analyses were performed. The maximum number of newly detected AF patients in The Netherlands ranged from 4554 to 39 270, depending on the screening strategy used. Adequate treatment with anticoagulation would result in a maximum of more than 3000 strokes prevented using single time point AF screening. Compared with no screening, screening 100 000 persons provided a gain in QALYs ranging from 984 to 8727, and a mean cost difference ranging from -6650 000€ to 898 000€, depending on the screening strategy used. Probabilistic sensitivity analysis (PSA) demonstrated a 100% likelihood that screening all patients ≥ 75 years visiting the Geriatric outpatient clinic was cost-saving. Four out of six strategies were cost-saving in ≥ 74% of the PSA simulations. Out of these, opportunistic screening of all patients ≥ 65 years visiting the GPs office had the highest impact on strokes prevented. Conclusion Most single-time point AF screening strategies are cost-saving and have an important impact on stroke prevention.

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Background: Geriatric patients are at risk of atrial fibrillation (AF) and stroke, and the risk of oral anticoagulation (OAC) related bleeding is also presumed to be higher. Detailed knowledge about the prevalence of AF and bleeding pattern in this population is scarce. This study sought to assess the prevalence of AF, use of OAC, and the rate of major bleeding in geriatric patients who are prone to frequent falls. We expect to find a higher prevalence of AF among geriatric patients compared to elderly people of comparable age. Methods: This was an observational cohort study conducted at the Fall and Syncope Clinic. Inclusion criteria: age >65 years, availability of both electrocardiogram (ECG) and Holter registration. The use and reasons to withhold OAC and the rate of major bleeding were retrieved from the medical files. Results: A total of 428 patients with the mean age of 79.8 years were analyzed. The mean number of morbidities was 11 ±5. AF was known in 98 (23%) patients, first diagnosed in 10 (2%). Among them, AF was paroxysmal in 45 (45%) patients, and 50% of them were first diagnosed cases. Of patients with AF, 84% were using OAC. The rate of major bleeding episodes was 1.1 per 100 treatment years. Major bleeding episodes were not different between the patients using antiplatelet agents (APA), OAC, or no antithrombotic medication. Conclusions: In this geriatric population, 23% of patients had AF and almost half were paroxysmal. Compared to previous studies, the use of OAC has substantially increased to 84% and no differences were found in the rate of major bleeding episodes between those using APA, OAC, or no antithrombotic medication.

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The Dutch population of first generation Turkish and Moroccan migrants is ageing. Among them hypertension and diabetes mellitus are frequent findings, which will probably cause an increased incidence of dementia. The language barrier, low education and cultural differences make the diagnosis more difficult. To what extent the MMSE can be used as a cognitive screener in this population will be investigated in this retrospective study.Patients received standard diagnostics, a professional translator addressed the language barrier. Correspondence was scored on characteristics of dementia, a procedure was used to diagnose without including the MMSE score. The optimal cut-off was calculated with the Youden Index and Area under the ROC (AUROC).106 patients were included, 61% had no education. Average MMSE-score was 16, with dementia 12, without 19. The AUROC was 0.85, optimal cut-off was 18 with a Youden index of 0.61.By using a professional translator the MMSE can possibly be used as a cognitive screener in this population. However, the cognitive skills addressed by the MMSE require an education and language skills. Developing a test that is independent of education and language barrier will probably be better.

Background Physicians can be reluctant to prescribe antithrombotic agents in frail elderly patients with frequent falls due to the fear for severe bleeding, mainly for intracranial haemorrhage (ICH). Presently, there is only a limited amount of inconclusive data available on the topic. Purpose Identification of risk factors for ICH within a cohort of geriatric patients with repeated falls. Methods All patients of 65 years of age and older with repeated falls at our day clinic were eligible. If an MRI of the brain was performed as part of the assessment, patients were included in this analysis. Baseline characteristics including medical, functional, and cognitive state were collected, a Frailty Index (FI) was calculated [1,2]. Cerebral small vessel disease was described and evaluated as proposed in a position paper in 2013 [3]. Follow-up data concerning major bleeding events were retrieved from the electronic medical files. Odds ratios (OR) with confidence intervals (CI) were calculated. Results 670 patients were eligible; an MRI was performed in 486 patients. The average age was 80 years, 50% was severely frail at the time of inclusion. 83 patients (17%) used OAC (mainly Vitamin K antagonists prescribed for atrial fibrillation), 165 patients (34%) used anti platelet agents (APA), 1 patient used both OAC and APA. In total, 29 major bleeding events (MB) occurred, of which 13 were ICH. Among patients using OAC, 8 MB occurred, of which 2 were ICH. The patient with both OAC and APA did not experience a bleeding event. Well known risk factors for ICH such as hypertension, diabetes mellitus and cognitive impairment were not predictive for ICH in this cohort, nor were the use APA (OR 0.86, 95% CI 0.26–2.84), or vitamin K antagonists (OR 0.88, 95% CI 0.19–4.05). However, a composite factor of using either APA or OAC, heightened the risk for MB (OR 3.24, 95% CI 1.35–7.74), but not for ICH (OR 0.83, 95% 0.27–2.49). Of cerebral small vessel disease, predictive factors for ICH were the presence of lacunes (OR 3.81, 95% CI 1.25–11.56), and relevant white matter hyperintensities (WMH) (defined as a Fazekas score of 2 or more) (OR 11.3, 95% CI 1.45–87.3). Furthermore, cognitive decline defined as an MMSE score of ≤26 heightened the risk of MB (OR 2.28, 95% CI 1.05–4.96). The low number of ICH did not allow for a multivariate analysis. Conclusion This analysis has several important findings. First, despite the long follow up of a cohort of severely frail patients that frequently fall, a low number of MB and ICH was observed. Second, well known risk factors for MB do not seem predictive of ICH in this cohort of very elderly patients. Finally, cognitive decline was predictive for MB, and WMH and lacunes were predictive for ICH. Adding cognitive screening and brain imaging to the diagnostic work up of patients with an indication for OAC could be of value when assessing the future risk for major bleeding events. FUNDunding Acknowledgement Type of funding sources: None.

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