Elderly atrial fibrillation patients lack adequate application of current management guidelines

Sep 5 2006

World Congress of Cardiology Report - Although elderly AF patients are at much higher risk for stroke, they are undertreated for stroke prophylaxis compared to younger patients.

Additionally, they do not receive appropriate rhythm control therapy when symptomatic with their AF. Therefore, management of elderly AF patients less often complies with guideline recommendations compared to younger AF patients.

AF is the most prevalent cardiac arrhythmia in the western world. Incidence of AF dramatically increases with advancing age, and often coincides with other heart diseases, mainly hypertension, heart failure and coronary artery disease. Since the frail and more diseased elderly are often excluded from randomised controlled trials – which form the basis of management guidelines – doctors are often hesitant to apply research results to the elderly, and tend to treat them more conservatively than younger patients.

The Euro Heart Survey on AF investigated in 2003-2005 management guideline adherence in 5,333 AF patients, among 35 ESC member countries. In order to assess differences in guideline adherence with increasing age, we compared elderly (>80 years) with young (<65 years) and medium aged (65-80 years) patients in our survey. Although elderly more often had multiple risk factors for stroke, they less often received oral anticoagulation than younger patients for the prevention of stroke. This relates to doctors’ and patients’ fear of bleeding. However, risk for stroke without oral anticoagulation is much higher than the risk for intracranial bleeding when applying oral anticoagulation. In agreement with results of randomised controlled trials, the survey found a very low incidence of intracranial bleeding. As long as oral anticoagulation is targeted at an INR range between 2.0 and 3.0, little time will be spent in the hazardous INR range above 4.0, and few intracranial bleedings will be attributable to this therapy.

In case of severe AF symptoms, termination of AF should be attempted to improve quality of life. Despite the presence of symptoms with their arrhythmia, rhythm control was frequently denied to elderly, probably due to their perceived frailness. Admittedly, risks of rhythm control are significant in the elderly. However, monitoring of these risks is feasible and should be implemented.

The Euro Heart Survey indicates the important issues in the management of elderly AF patients in daily cardiology practice. Management of old AF patients less often complies with guideline recommendations compared to younger patients. Trials including old patients and education on unjustified fears for side effects of therapy might strengthen doctors’ confidence to adhere to management guidelines.