EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA)

Abstract

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

Anticoagulation in Patients With Atrial Fibrillation Who Are Frail—Toward Better Care

“…Taken together, the findings of Lin and colleagues seem in accordance with a 2023 international consensus statement that advocates for the preferable use of DOACs in patients with AF who are frail, given their expected greater absolute benefit due to higher thromboembolic risk . Even more, the study by Lin et al paves the way for further investigations in patients with AF who are frail.…”

Assessment and Management of Atrial Fibrillation in Older Adults with Frailty

“…Finally, in all older adults with an implantable cardiac device with an atrial lead, regular device interrogation is recommended regardless of AF stage [1,2]. During the screening process, clinicians can consider following an integrated care approach using the Atrial fibrillation Better Care (ABC) pathway [51,52]. For frail adults at risk of AF or considered to be pre-AF, efforts must be focused on risk factor management and comorbidities optimization.…”

“…The choice of antiarrhythmic medication can be challenging for frail older adults, given multimorbidity, polypharmacy, and altered pharmacokinetics that can increase the risk of adverse effects [52]. Common contraindications for antiarrhythmic drugs in older adults include structural heart disease, QT prolongation, and renal failure [76].…”

Safety of Switching from a Vitamin K Antagonist to a Non-Vitamin K Antagonist Oral Anticoagulant in Frail Older Patients with Atrial Fibrillation: Results of the FRAIL-AF Randomized Controlled Trial

“…3,4 Many of these patients have the frailty syndrome, a clinical entity of accumulating comorbidities and polypharmacy, defined by a high biological vulnerability, dependency on significant others, and a reduced capacity to resist stressors. [5][6][7] These patients with AF living with frailty, currently receiving VKA treatment, are managed mainly in an outpatient setting, close to the communities where they live, by family medicine specialists, cardiologists, or internists.…”

“…In daily practice, physicians will implicitly weigh multiple factors when deciding on the optimal anticoagulant treatment that is very difficult to adjust for in observational studies. 5,11 Monitoring through international normalized ratio (INR) testing allows for intervening at an early stage by titrating the VKA dose to the most optimal range, which may be beneficial in older patients living with frailty given their larger volatility in anticoagulant status. As a result, it is uncertain whether the superiority of NOACs over VKAs in patients with AF observed also holds for frail patients with AF, and the question whether these patients with AF taking VKA should be switched to an NOAC remains heavily debated.…”