scholarly journals Rate and rhythm control treatment in the elderly and very elderly patients with atrial fibrillation: an observational cohort study of 1,497 patients

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
T.A Klamer ◽  
S.H Bots ◽  
J Neefs ◽  
I.I Tulevski ◽  
G.A Somsen ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Control Strategy ◽  
Rate Control ◽  
The Elderly ◽  
Rhythm Control ◽  
Prescribing Patterns ◽  
Very Elderly ◽  
Electronic Health Record Data ◽  
To Receive

Abstract Aim Stroke prevention and rate or rhythm control are crucial parts of the treatment of atrial fibrillation (AF). There is limited evidence for the efficacy or safety of rate and rhythm control in elderly or very elderly patients, although this population is rapidly increasing. Therefore, we analyzed electronic health record data from outpatient cardiology clinics to give insight in prescribing patterns and mortality of both treatment strategies in the elderly patients. Methods and results We extracted data from all patients with AF who were aged >75 years, used a pharmacological rate or rhythm control strategy and visited one of the independent outpatient cardiology clinics in the Netherlands between 2007 and February 2018. This resulted in 1,497 selected patients (54% women), of whom 316 (21%) were prescribed rhythm control (consisting of class 1 or 3 antiarrhythmic drugs) and 1,181 (79%) rate control (beta blockers, calcium antagonists or digoxin). Patients aged >85 years (OR: 2.28) and those with permanent AF (OR: 2.71) were more likely to receive rate control (OR: 2.28, OR: 2.71 respectively), whereas those with paroxysmal AF were more likely to receive rhythm control (OR: 0.42). After correcting for relevant confounders, the mortality risk for patients using rhythm control was similar to patients using rate control (HR: 0.89; 95% CI: 0.70; p=0.31). Conclusion Considering the similar mortality risks in both groups, a more liberal approach in prescribing a rhythm control strategy to the healthier elderly patient with AF seems safe. Our data underscores the need for a non-inferiority trial to provide definite answers on safety of rhythm control in elderly patients with AF. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals Rate-control vs rhythm-control of atrial fibrillation in elderly patients. From new, age-oriented outcomes to a more complex management strategy

2018 ◽  
Vol 88 (2) ◽  
Author(s):  
Stefano Fumagalli ◽  
Serena Boni ◽  
Simone Pupo ◽  
Marta Migliorini ◽  
Irene Marozzi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Control Strategy ◽  
Rate Control ◽  
The Elderly ◽  
Epidemiological Studies ◽  
Rhythm Control ◽  
Aged Patients ◽  
Aged People ◽  
Arrhythmia Management

Atrial fibrillation (AF) is the most frequent arrhythmia in elderly people. Findings derived from clinical trials seem to demonstrate that a rate-control strategy of AF in aged patients improves prognosis if compared to a rhythm-control one. However, epidemiological studies concordantly show that the arrhythmia is associated to increased hospitalization and mortality rates. In last years, the proportion of patients admitted to hospital for AF has progressively increased; this trend is observed in subjects >75 and >85 years, while no change was found in younger cohorts. Importantly, in aged individuals, probably because of the loss of atrial activity, the increase of heart rate and the irregularity of RR intervals, AF begins a vicious cycle, leading from heart failure, through the compromise of functional and neurocognitive status, to overt disability, dementia and increased mortality. Evidence specifically aimed at clarifying the effects of arrhythmia management on outcomes characteristic of aged people is completely lacking. In the elderly, the question regarding the effects of a rate- or a rhythm-control strategy of AF should be considered as an aspect of a more complex strategy, addressed to reduce disability and hospitalizations, and to improve quality of life and survival.

Abstract P111: Sex Differences in Rate or Rhythm Control and Outcomes Among Elderly Patients With Atrial Fibrillation

Circulation ◽  
2020 ◽  
Vol 141 (Suppl_1) ◽  
Author(s):  
Vinita Subramanya ◽  
J'Neka S Claxton ◽  
Pamela L Lutsey ◽  
Richard MacLehose ◽  
Alanna M Chamberlain ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Major Bleeding ◽  
Rate Control ◽  
Treatment Strategy ◽  
Cox Regression ◽  
Rhythm Control ◽  
To Receive

Introduction: Women with atrial fibrillation (AF) experience greater symptomatology, worse quality of life, and have a higher risk of stroke as compared to men, but are less likely to receive rhythm control for the treatment of AF. Whether these differences exist in elderly patients with AF, and whether sex modifies the effectiveness of rhythm versus rate control therapy has not been assessed. Methods: We studied 135,850 men and 139,767 women 75 years or older diagnosed with AF in the MarketScan Medicare database between 2007-2015. Rate control was defined as use of rate control medication or atrioventricular node ablation. Rhythm control was defined by use of anti-arrhythmics, catheter ablation or cardioversion. Participants on both rate and rhythm were coded under rhythm control. We used multivariable logistic and Cox regression models to estimate 1) the association of sex and treatment strategy (within 30-day post AF diagnosis and entire follow-up) and, 2) the association of treatment strategy with incident heart failure, stroke and major bleeding. Results: Men were on average (SD) 82.5 (5.2) years old and women 83.8 (5.6) years, respectively. Women were less likely to receive rhythm control treatment as compared to men in the 30-day post AF diagnosis period (22% vs 27%), (OR 0.91, 95% CI 0.88, 0.94) and over the entire duration of follow-up (28% vs 32%) (HR 0.93, 95% CI 0.90, 0.96). Rhythm (vs. rate) control was associated with a higher risk of heart failure in women [HR 1.41, 95% CI 1.34, 1.49] than in men [HR, 1.21 95% CI 1.15, 1.28] (p for multiplicative interaction < 0.001, Table ). Sex did not modify associations between treatment and incident stroke or major bleeding events. Conclusion: Women aged 75 years and older were less likely to be prescribed rhythm control as compared to men, and experienced higher risk of heart failure than men when receiving rhythm (vs rate) control. Future studies will need to delve into the mechanisms underlying these differences.

scholarly journals Rhythm-control vs rate-control in the elderly: When to do it and which drug to prefer?

2018 ◽  
Vol 88 (2) ◽  
Author(s):  
Giovanni Luca Botto ◽  
Carlo Piemontese ◽  
Giovanni Russo
Keyword(s):  
Atrial Fibrillation ◽  
Elderly Patient ◽  
Rate Control ◽  
Ischemic Cardiomyopathy ◽  
Elderly Population ◽  
Antiarrhythmic Drugs ◽  
Treatment Options ◽  
The Elderly ◽  
Rhythm Control ◽  
Abnormal Rate

Atrial fibrillation (AF) is a relevant cardiovascular condition that is more prevalent in the elderly patients aged over 65 years. AF, with abnormal rate and rhythm can cause symptoms directly or indirectly by exacerbating other frequently coexisting cardiac conditions such as valvular heart disease, hypertension, ischemic cardiomyopathy, dilated cardiomyopathy, and hypertrophic cardiomyopathy. Evidence suggests that aging-related cardiovascular changes predispose to the elderly to AF. Current therapeutic options such as antiarrhythmic drugs have not been extensively evaluated in the elderly population. Emerging pharmacological and non-pharmacological treatment options for the management of AF, such as dronedarone or catheter ablation, are of particular interest in the elderly. The present paper reviews the pathophysiology, diagnosis, and the management of AF in the elderly patient.

3153Rate versus rhythm control and mortality in atrial fibrillation patients: a Danish nationwide cohort study

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
F Dalgaard ◽  
S Al-Khatib ◽  
J Pallisgaard ◽  
C Torp-Pedersen ◽  
T B Lindhardt ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Heart Disease ◽  
Control Strategy ◽  
Rate Control ◽  
Channel Blocker ◽  
Rhythm Control ◽  
All Cause Mortality ◽  
Control Therapy

Abstract Background Treatment of AF patients with rate or rhythm drug therapy have shown no difference in mortality in clinical trials. However, the generalizability of these trials to real-world populations can be questioned. Purpose We aimed to investigate the all-cause and cardiovascular (CV) mortality risk in a nationwide AF cohort by treatment strategy (rate vs. rhythm) and by individual drug classes. Methods We queried the Danish nationwide registries from 2000 to 2015 to identify patients with AF. A rate control strategy included the use of one or more of the following medications: beta-blocker, digoxin, and a class-4 calcium channel blocker (CCB). A rhythm control strategy included the use of an anti-arrhythmic drug (amiodarone and class-1C). Primary outcome was all-cause mortality. Secondary outcome was CV mortality. Adjusted incidence rate ratios (IRR) were computed using Poisson regression with time-dependent covariates allowing patients to switch treatment during follow-up. Results Of 140,697 AF patients, 131,793 were on rate control therapy and n=8,904 were on rhythm control therapy. At baseline, patients on rhythm control therapy were younger (71 yrs [IQR: 62–78] vs 74 [65–82], p<0.001) more likely male (63.5% vs 51.7% p<0.001), had more prevalent heart failure (31.1% vs 19.4%, p<0.001) and ischemic heart disease (40.1% vs. 23.3%, p<0.001), and had more prior CV-related procedures; PCI (7.4% vs. 4.0% p<0.001) and CABG (15.0% vs. 2.3%, p<0.001). During a median follow up of 4.0 (IQR: 1.7–7.3) years, there were 64,653 (46.0%) deaths from any-cause, of which 27,025 (19.2%) were CVD deaths. After appropriate adjustments and compared to rate control therapy, we found a lower IRR of mortality and CV mortality in those treated with rhythm control therapy (IRR: 0.93 [95% CI: 0.90–0.97] and IRR 0.84 [95% CI: 0.79–0.90]). Compared with beta-blockers, digoxin was associated with increased risk of all-cause and CV mortality (IRR: 1.26 [95% CI: 1.24–1.29] and IRR: 1.32 [95% CI: 1.28–1.36]), so was amiodarone: IRR for all-cause mortality: 1.16 [95% CI: 1.11–1.21] and IRR for CV mortality: 1.12 [95% CI: 1.05–1.19]. Class-1C was associated with lower all-cause (0.43 [95% CI: 0.37–0.49]) and CV mortality (0.35 [95% CI: 0.28–0.44]). Figure 1. Models were adjusted for age, sex, ischemic heart disease, stroke, chronic obstructive pulmonary disease, chronic kidney disease, valvular atrial fibrillation, bleeding, diabetes, ablation, pacemaker, implantable cardioverter defibrillator, hypertension, heart failure, use of loop diuretics, calendar year, and time on treatment. Abbreviations; CCB; calcium channel blocker, PY; person years. Conclusions In a real-world AF cohort, we found that compared with rate control therapy, rhythm control therapy was associated with a lower risk of all-cause and CV mortality. The reduced mortality risk with rhythm therapy could reflect an appropriate patient selection. Acknowledgement/Funding The Danish Heart Foundation

scholarly journals Quality indicators for the care and outcomes of adults with atrial fibrillation

EP Europace ◽  
2020 ◽  
Author(s):  
Elena Arbelo ◽  
Suleman Aktaa ◽  
Andreas Bollmann ◽  
André D’Avila ◽  
Inga Drossart ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Risk Factor ◽  
Quality Indicators ◽  
Control Strategy ◽  
Rate Control ◽  
Rhythm Control ◽  
Patient Assessment ◽  
Risk Factor Management ◽  
Diagnosis And Management

Abstract Aims To develop quality indicators (QIs) that may be used to evaluate the quality of care and outcomes for adults with atrial fibrillation (AF). Methods and results We followed the ESC methodology for QI development. This methodology involved (i) the identification of the domains of AF care for the diagnosis and management of AF (by a group of experts including members of the ESC Clinical Practice Guidelines Task Force for AF); (ii) the construction of candidate QIs (including a systematic review of the literature); and (iii) the selection of the final set of QIs (using a modified Delphi method). Six domains of care for the diagnosis and management of AF were identified: (i) Patient assessment (baseline and follow-up), (ii) Anticoagulation therapy, (iii) Rate control strategy, (iv) Rhythm control strategy, (v) Risk factor management, and (vi) Outcomes measures, including patient-reported outcome measures (PROMs). In total, 17 main and 17 secondary QIs, which covered all six domains of care for the diagnosis and management of AF, were selected. The outcome domain included measures on the consequences and treatment of AF, as well as PROMs. Conclusion This document defines six domains of AF care (patient assessment, anticoagulation, rate control, rhythm control, risk factor management, and outcomes), and provides 17 main and 17 secondary QIs for the diagnosis and management of AF. It is anticipated that implementation of these QIs will improve the quality of AF care.

scholarly journals Choice and Outcomes of Rate Control versus Rhythm Control in Elderly Patients with Atrial Fibrillation: A Report from the REPOSI Study

Drugs & Aging ◽  
2018 ◽  
Vol 35 (4) ◽  
pp. 365-373 ◽  
Author(s):  
Francesco Paciullo ◽  
◽  
Marco Proietti ◽  
Vanessa Bianconi ◽  
Alessandro Nobili ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Rate Control ◽  
Rhythm Control ◽  
Control Versus

Rate versus rhythm control therapy for atrial fibrillation

2018 ◽  
Author(s):  
Albert L. Waldo
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Control Strategy ◽  
Rate Control ◽  
Anticoagulation Therapy ◽  
Rhythm Control ◽  
Rate Versus ◽  
Ventricular Response ◽  
Tachycardia Induced Cardiomyopathy ◽  
Stable Sinus Rhythm

Based on data from several clinical trials, either rate control or rhythm control is an acceptable primary therapeutic strategy for patients with atrial fibrillation. However, since atrial fibrillation tends to recur no matter the therapy, rate control should almost always be a part of the treatment. If a rhythm control strategy is selected, it is important to recognize that recurrence of atrial fibrillation is common, but not clinical failure per se. Rather, the frequency and duration of episodes, as well as severity of symptoms during atrial fibrillation episodes should guide treatment decisions. Thus, occasional recurrence of atrial fibrillation despite therapy may well be clinically acceptable. However, for some patients, rhythm control may be the only strategy that is acceptable. In short, for most patients, either a rate or rhythm control strategy should be considered. However, for all patients, there are two main goals of therapy. One is to avoid stroke and/or systemic embolism, and the other is to avoid a tachycardia-induced cardiomyopathy. Also, because of the frequency of atrial fibrillation recurrence despite the treatment strategy selected, patients with stroke risks should receive anticoagulation therapy despite seemingly having achieved stable sinus rhythm. For patients in whom a rate control strategy is selected, a lenient approach to the acceptable ventricular response rate is a resting heart rate of 110 bpm, and probably 90 bpm. The importance of achieving and maintaining sinus rhythm in patients with atrial fibrillation and heart failure remains to be clearly established.

scholarly journals Rhythm control in patients with atrial fibrillation and heart failure: a meta-analysis of randomized controlled trials

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
S.Z Ramos ◽  
A.L.D Te-Rosano
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Risk Ratio ◽  
Control Strategy ◽  
Rate Control ◽  
Meta Analysis ◽  
Rhythm Control ◽  
Forest Plot ◽  
Randomized Controlled ◽  
All Cause Mortality

Abstract Background Atrial fibrillation (AF) is a common arrhythmia that can promote or worsen heart failure (HF). Limited data exist to guide treatment for patients with AF with HF regarding rate versus rhythm control. Purpose To perform a meta-analysis of randomized controlled trials (RCT) in the determination of the efficacy of rhythm control as compared to rate control among patients with AF and HF. Methods Extensive search of PubMed, Cochrane Library, Ovid, EMBASE, Google scholar, and Medline was done up to October 2020. Studies were limited to RCTs comparing rhythm control in patients with atrial fibrillation and heart failure with rate control. Outcome measures include all-cause mortality and cardiovascular mortality. Statistical analysis was done using Review manager V5.3. Results A total of 9800 patients were included in the pooled analysis of the comparison of rhythm control versus rate control strategy in patients with AF and HF. All pooled analyses were done using random effects model. The pooled risk ratio for all-cause mortality of rate control vs rhythm control did not achieve significance at 1.15, with 95% CI 0.91 to 1.45, and p=0.24. There was statistically significant heterogeneity across the two studies with I2 of 54% and p=0.02 (Figure 1A). The pooled risk ratio for cardiovascular mortality in rate control strategy vs rhythm control is 1.19, with 95% CI 0.94 to 1.50, and p=0.15 (Figure 1B). Eight trials with 9987 participants reported stroke. The pooled risk ratio of stroke in rate control vs rhythm control is 1.11, with 95% CI 0.84 to 1.46, and p=0.47 (Figure 1C). The 95% CI for the pooled risk ratio cross 1.00, indicating an equivocal result. Our results do not indicate statistical heterogeneity across the studies with I2 of 28% and p=0.27. Seven trials with 8311 participants reported bleeding. The pooled risk ratio of hospitalization for bleeding in rate control vs rhythm control is 1.18, with 95% CI 0.81 to 1.73, and p=0.39 (Figure 1D). Thus, we have insufficient evidence to demonstrate whether rate or rhythm control have significantly higher or lower risk for bleeding. Four trials with 8468 participants reported hospitalization rate. The pooled risk ratio of hospitalization in rate control compared to rhythm control is 0.96, with 95% CI 0.86 to 1.07, and p=0.42 (Figure 1E). None of the studies individually showed statistically significant differences but AF–CHF showed benefit of rate control in the first year after enrolment (p=0.001) and a tendency favouring rate control (p=0.06) when the study was analysed in full length except for AF-CHF. Conclusion Among patients with AF and concomitant HF, there is no sufficient evidence between rate and rhythm control strategies in their effects to rates of mortality and major clinical outcomes; therefore, choosing an appropriate therapeutic strategy should consider individual variations such as patient preferences, comorbidities, and treatment cost. FUNDunding Acknowledgement Type of funding sources: None. Forest Plot A–C Forest Plot D–E

scholarly journals 2206. Patterns of Care and Outcomes in Elderly Patients Hospitalized with Community-acquired Pneumonia in the United States

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S752-S752
Author(s):  
Radhika Rastogi ◽  
Abhishek Deshpande ◽  
Phuc Le ◽  
Pei-Chun Yu ◽  
Peter Imrey ◽  
...  
Keyword(s):  
Elderly Patients ◽  
The Elderly ◽  
The United States ◽  
Community Acquired Pneumonia ◽  
Patterns Of Care ◽  
Principal Diagnosis ◽  
Very Elderly ◽  
Lengths Of Stay ◽  
Tract Infections ◽  
To Receive

Abstract Background Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality in the elderly. Few studies compare the elderly (>65) and very elderly (≥85 years). We aimed to describe characteristics and patterns of care for very elderly patients hospitalized with CAP. Methods We conducted a retrospective cohort study using administrative data from 2010 to 2015 of about 660 US hospitals in the Premier database. Adults aged ≥65 years hospitalized with CAP, identified by either a principal ICD-9 code of pneumonia or a principal diagnosis of sepsis or respiratory failure coupled with a secondary code for pneumonia, were included. We compared demographics, insurance status, comorbidities, presentation characteristics and treatments among three age groups: 65–74, 75–84, and ≥ 85 years. Results The final sample included 488,382 patients aged ≥65 years, a third of whom were ≥85 years. Geriatricians cared for <1% of patients during hospitalization, regardless of patient age. Compared with those aged 65–74 years, the patients ≥85 were more likely to be female, of white race, have Medicare insurance, and a principal diagnosis of aspiration pneumonia (17.1% vs. 7%) (Table 1). The oldest group had higher rates of cardiac comorbidities, chronic kidney disease and dementia, but lower rates of diabetes, obesity, pulmonary disease, and smoking. On presentation, more of the very elderly had concomitant urinary tract infections. They were less likely to receive opiates and benzodiazepines, but more likely to receive foley catheters and antipsychotic medications. Antibiotics given in the first 2 days were similar across the groups. Fewer very elderly patients were admitted to the ICU or got ventilation compared with younger groups. More of the very elderly were discharged to hospice and fewer were discharged home. Compared with younger ages, the very elderly had similar lengths of stay but lower costs, and higher in-hospital mortality and 30-day readmission. Conclusion The very elderly represent a unique population with distinct clinical characteristics and outcomes from younger elderly patients. They have different co-morbidities and appear to receive less aggressive treatment with lower costs and higher mortality despite similar lengths of stay. Disclosures All authors: No reported disclosures.

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