This guide has been developed to assist healthcare providers in managing atrial fibrillation in older adults. It is based on two publications of the AGS (americangeriatrics.org); the 7th edition of The Geriatrics Review Syllabus and 2012 edition of Geriatrics At Your Fingertips.™
Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice.1
- Currently, approximately 70% of patients with AF are between 65 and 85 years old, and it is projected that by 2050 half of all adults with AF will be ≥80 yr old.2
- AF is an independent predictor of mortality in older adults.3
- AF accounts for about 1.5% of strokes in patients 50-59 yr old but 23.5% of strokes in patients 80-89 yr old.4
- Women with AF are at increased risk of stroke relative to men, especially after age 75.3
- Cardiac: cardiac surgery, cardiomyopathy, HF, hypertensive heart disease, ischemic disease, pericarditis, valvular disease.
- Noncardiac: alcoholism, chronic pulmonary disease, infections, pulmonary emboli, thyrotoxicosis.
- Symptoms related to AF are highly variable.
- Most common:
- Shortness of breath
- Impaired exercise tolerance
- Some patients are entirely asymptomatic, while others present with an exacerbation of heart failure or an embolic complication.
- In patients with ongoing AF, the standard 12-lead electrocardiogram is diagnostic. Additional laboratory studies should include:
- Evaluation of serum electrolytes (especially potassium and magnesium)
- Assessment of thyroid function
- Complete Blood Count (CBC) Test
- A transthoracic echocardiogram is indicated in all patients with new-onset AF to evaluate LV size and function, left atrial size, pulmonary artery pressure and the cardiac valves.
- Further evaluation in selected cases might include a chest radiograph, serial cardiac biomarker proteins to exclude acute MI, a brain natriuretic peptide level, a D-dimer level, leg venous Dopplers, and an evaluation for pulmonary embolism.
Risk Factor Modification
- Stop smoking
- Reduce BP to at least 140/90 mmHg; 120/80 mmHg is desirable
- In patients ≥80 yr old with few cardiovascular comorbidities, 150/80 mmHg is a reasonable BP treatment goal
- Treat dyslipidemia
- Start anticoagulation or antiplatelet therapy for AF
- Low-sodium (<2.3 g/d), high-potassium (4.7 g/d) diet
- Exercise (30 min. of moderate intensity activity daily)
- Maintain weight within appropriate range
STROKE RISK USING CHADS25
- CHADS2 assigns 1 point for congestive heart failure,hypertension, age ≥75 years, and diabetes and 2 points for prior stroke or transient ischemic attack.
- Annual stroke risk increases from about 2% in patients with a CHADS2 score of 0 to about 18% in patients with a CHADS2 score of 6. In general, patients with a CHADS2 score of 0 are at low risk of stroke.
- Note that all patients ≥75 years old have a CHADS2 score of at least 1, and the vast majority will have a score of ≥2 (given the high prevalence of hypertension, diabetes and congestive heart failure in this age group).
- All older adults with a CHADS2 score of 2 or higher should be considered for anticoagulation therapy, regardless of whether a rate-control or rhythm-control strategy is used.
The objectives of therapy for AF include relieving symptoms and minimizing the risk of thromboembolic events, particularly stroke.7
PRINCIPAL STRATEGIES FOR RELIEVING SYMPTOMS7
- Control of heart rate
- Maintenance of normal sinus rhythm
- Correct precipitating cause.
“RATE CONTROL” VS. “RHYTHM CONTROL”
1Prystowsky EN, Benson DW, Fuster V, et al. Management of Patients with Atrial Fibrillation: A Statement for Healthcare Professionals from the Subcommittee on Electrocardiography and Electrophysiology, from the American Heart Association. Circulation. 1996; 93:1262- 1277.
2Fuster V, Rydén LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: A report of the American College of Cardiology Foundation/American Heart As- sociation Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol. 2011 Mar 15;57(11):e101-98. doi: 10.1016/j. jacc.2010.09.013.
3 Go AS, Mozaffarian D, Roger VL, et al. Heart Disease and Stroke Statistics — 2012 Update. Circulation. 2012;125:e2-e220.
4 Wolf PA, et al. Atrial Fibrillation as an Independent Risk Factor for Stroke: the Framingham Study. Stroke. 1991; 22:983-988.
5 Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: full text: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation); Developed in Collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006; 8; 651-745.
6 Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, et al. Guidelines for the Primary Prevention of Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2011; 42:517-584.
7 NHLBI website. How is Atrial Fibrillation Treated? Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/af/treatment.html. Accessed on: December 11, 2012.
8 Guttierez C, Blanchard DG. Atrial Fibrillation: Diagnosis and Treatment. American Family Physician. 2011; 83(1):61-68.
// Additional Resources
- iGeriatrics is a mobile application available in the Apple App Store and the Android Market which includes a mobile app on AF management. More information and additional geriatrics tools and guidelines can be found on GeriatricsCareOnline.org.
- Free public education resources on AF are available at HealthInAging.org.