Saturday, July 15, 2017

Management of atrial fibrillation in the elderly

The elderly are under represented in clinical trials. This review summarizes the available evidence for the management of AF in the elderly. The conclusions of this evidence synthesis are in line with current AF recommendations in general:

Stroke prophylaxis

Elderly adults with AF are at greater risk than those without AF of stroke without anticoagulation and greater risk of bleeding with anticoagulation, posing a therapeutic challenge

Studies assessing the net clinical benefit of anticoagulation (which weighs the risk of ischemic stroke against the risk of major bleeding) demonstrate a significant benefit of anticoagulation in most elderly adults

Recently available direct oral anticoagulants may tip the balance further in favor of anticoagulation by reducing the rate of major bleeding, in particular intracranial hemorrhage

Evidence to support antiplatelet therapy for AF stroke prophylaxis is relatively weak, and in general, antiplatelet agents should have a limited role

In elderly adults who are unable to undergo long-term anticoagulation, percutaneous left atrial appendage occlusion devices may provide a reasonable alternative, although data are still emerging in this area

Symptom management

As a routine strategy, there is no benefit of rhythm control (using anti-arrhythmic drugs, cardioversion, or both) over rate control with AV nodal blocking agents

In individuals treated using rate control, a lenient strategy (target resting heart rate less than 110 bpm) is as effective for symptom control as strict rate control (target resting heart rate less than 80)

Individuals who cannot tolerate rate-slowing agents or those with tachycardia–bradycardia syndrome may benefit from pacemaker implantation plus AV nodal blocking drugs or ablation of the AV node

AF catheter ablation may be beneficial in appropriately selected elderly adults with inadequately controlled symptoms on medical therapy, although data on outcomes of ablation in elderly adults are limited

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