Atrial fibrillation in the elderly population: Challenges and management considerations

Abstract

Importance Atrial fibrillation is the most clinically significant arrhythmia in humans when viewed both from a global and also a national perspective. In the United States, approximately 2.7‐6.1 million people are estimated to have atrial fibrillation. With the aging of the population, this prevalence is on an increasing trend and remains an obstacle to cardiovascular health despite significant advancements specific to cardiovascular disease management. Observation In this specific group of patients, healthcare utilization is a concern from the public health perspective. Unfortunately, misconceptions dominate clinical decision making; for instance, the avoidance of safe and effective anticoagulation strategies in patients at the highest risk for embolic strokes continues to be widespread in clinical practice and is often based on a skewed assessment of risk versus benefit. Also, when there are contraindications to standard interventions for atrial fibrillation, a clear and nuanced understanding of second‐ and third‐line interventions with proven benefit is often lacking. Conclusions and Relevance An individualized approach should be followed by physicians when managing atrial fibrillation in the elderly patient, taking into consideration the risk of complications, particularly the embolic stroke and the availability of treatment options for stroke prevention whether through pharmacological anticoagulation or left atrial appendage occluding devices. The following review sets out to clarify these issues.

Clinical features and outcomes of patients in different age groups with non-valvular atrial fibrillation receiving oral anticoagulants

“…For very elderly patients with NVAF, lower dosages of NOACs were used or lower INR target of VKA was achieved (e.g., dabigatran 110 mg twice daily, rivaroxaban 15 mg once daily, edoxaban 30 mg once daily, apixaban 2.5 mg twice daily, warfarin INR target 1.6–2.6) [10] , [11] , [12] , [13] , [14] . Decisions to prescribe reduced dose NOACs or low INR target VKA are made based on the specific considerations on age, weight, renal function and use of specific concomitant medications.…”

“…Some previous studies [27] , [28] , [29] , [30] suggest that inappropriate dose reduction has been associated with a higher risk for embolism in patients with NVAF. Therefore, we conditionally adjusted the dosage of NOACs strictly following the recommendations from updated guidelines and consensus (age, glomerular filtration rate [eGFR], weight, history of bleeding or need to be combined with a strong P glycoprotein inhibitor or antiplatelet medicine) in whole study subjects [13] , [14] , [31] . The individual lower dosage of NOACs medication plans in our very elderly patients with NVAF included dabigatran 110 mg twice daily, rivaroxaban 15 mg once daily, edoxaban 30 mg once daily, apixaban 2.5 mg twice daily.…”

Rate vs Rhythm Control Strategy for Atrial Fibrillation in 2022

“…Choice of AAD is often dictated by its availability, thus amiodarone is used more frequently, followed by class IC agent (flecainide, propafenone prefer rate control in the elderly, as they commonly have persistent or permanent AF with left atrial enlargement, the latter leads to failure of rhythm control AADs to restore sinus rhythm and risks proarrhythmogenicity. 10 In fact, rate control is safe in the elderly with a comparable improvement in QOL as with rhythm control, the latter often associated with a higher rate of hospitalization. AF in elderly can incite decompensatory episodes of pre-existing HF, digoxin is an effective rate control agent in this setting.…”

Global research progress on radiofrequency ablation in cardiology: A bibliometric analysis (2004–2023)

“…With the aging global population, the incidence of arrhythmias, especially atrial fibrillation (AF), is increasing globally. [1][2][3] AF increases the risk of stroke and heart failure and is linked to higher mortality rates. [3][4][5] A study [2] reports that the number of AF patients in the United States is expected to reach 6 to 16 million by 2050, and at least 72 million in Asia, significantly burdening healthcare systems.…”