Influence of advancing age on clinical presentation, treatment efficacy and safety, and long-term outcome of pre-excitation syndromes: a retrospective cohort study of 961 patients included over a 25-year period

Abstract

ObjectivesThere are very little data on pre-excitation syndrome (PS) in the elderly. We investigated the influence of advancing age on clinical presentation, treatment and long-term outcome of PS.SettingSingle-centre retrospective study of patient files.ParticipantsIn all, 961 patients (72 patients ≥60 years (mean 68.5±6), 889 patients <60 years (mean 30.5±14)) referred for overt pre-excitation and indication for electrophysiological study (EPS) were followed for 5.3±5 years. Usual care included 24 h Holter monitoring, echocardiography and EPS. Patients underwent accessory pathway (AP) ablation if necessary.Primary and secondary outcome measuresOccurrence of atrial fibrillation (AF) or procedure-induced adverse event.ResultsElectrophysiological data and recourse to AP ablation (43% vs 48.5%, p=0.375) did not significantly differ between the groups. Older patients more often had symptomatic forms (81% vs 63%, p=0.003), history of spontaneous AF (8% vs 3%, p=0.01) or adverse presentation (poorly tolerated arrhythmias: 18% vs 7%, p=0.0009). In multivariable analysis, patients ≥60 years had a significantly higher risk of history of AF (OR=4.2, 2.1 to 8.3, p=0.001) and poorly tolerated arrhythmias (OR=3.8, 1.8 to 8.1, p=0.001). Age ≥60 years was associated with an increased major AP ablation complication risk (10% vs 1.9%, p=0.006). During follow-up, occurrence of AF (13.9% vs 3.6%, p<0.001) and incidence of poorly tolerated tachycardia (4.2% vs 0.6%, p=0.001) were more frequent in patients ≥60 years, although frequency of ablation failure or recurrence was similar (20% vs 15.5%, p=0.52). In multivariable analysis, patients ≥60 years had a significantly higher risk of AF (OR=2.9, 1.2 to 6.8, p≤0.01).ConclusionsIn this retrospective monocentre study, patients ≥60 years referred for PS work up appeared at higher risk of AF and adverse presentation, both prior and after the work up. These results suggest that, in elderly patients, the decision for EPS and AP ablation should be discussed in light of their suspected higher risk of events and ablation complications. However, these findings should be further validated in future prospective multicentre studies.

Electrocardiographic Preexcitation and Risk of Cardiovascular Morbidity and Mortality

“…Although these results should be interpreted with great caution because of relatively low statistical power for the 2 subgroups, our finding is in line with a recent study indicating that tachycardia is poorly tolerated among individuals with preexcitation ≥60 years compared with those <60 years. 28 With this finding, combined with the fact that the burden of AF is known to increase with age, it seems biologically plausible that the elderly patients are those most vulnerable to preexcitation. Further studies are needed to determine whether this novel finding should affect clinical decision making.…”

Arrhythmias in Patients ≥80 Years of Age

“…A retrospective evaluation of 961 patients with AV re-entrant tachycardia, about one-half of whom underwent ablation, compared long-term outcomes in their elderly (age >65 years) cohort compared with their younger patients at an average follow-up of 5.6 years (47). The incidence of poorly tolerated tachycardia (4.2% vs. 0.6%; p = 0.001) and the risk of major complications (10% vs. 1.9%; p = 0.006) were more frequent in elderly patients.…”

Unresolved questions associated with the management of ventricular preexcitation syndrome

“…In the elderly, the shortest atrial pacing cycle length with 1/1 anterograde conduction via the AP increased progressively with age . However, the propensity for AF was shown to be higher in older patients compared to younger patients .…”

“…AF easily is induced during intracardiac studies by salvos of rapid atrial stimulation and is not specific . Important variations of the incidence of induced AF depends on the technique of programmed stimulation, of the interpretation of the duration of induced arrhythmia, the use of isoproterenol infusion, the presence of associated heart disease, and on the age of the patient: AF is rarely induced in children younger than 10 years, is induced in 20% of teenagers and adults without heart disease, and becomes relatively frequent in the elderly (31%) . Ventricular tachyarrhythmias are not uncommonly induced in asymptomatic or symptomatic patients by programmed ventricular stimulation and are not specific for a risk of cardiac arrest in PS …”