Original Study
Treatment of Nonagenarians With Atrial Fibrillation: Insights From the Berlin Atrial Fibrillation (BAF) Registry

https://doi.org/10.1016/j.jamda.2015.05.012Get rights and content

Abstract

Objectives

The objective of this study was to determine course and treatment of atrial fibrillation (AF) in nonagenarians. Incidence of AF increases with age. Due to the demographic change in the industrialized world, an increase of AF in the group of elderly and very elderly is expected in the next decades. However, only few data exist on the clinical relevance of AF in patients aged 89 years or older.

Design

Observational, mono-centric registry.

Setting

University hospital.

Participants

Of the 11,888 patients included in the Berlin Atrial Fibrillation (BAF) Registry, 279 patients aged 89 years or older were identified. All patients presented to our hospital with AF between January 2001 and December 2014.

Measurements

AF type, symptoms, comorbidities, CHA2DS2-VASc and HAS-BLED, treatment strategy, and anticoagulant treatment were assessed at baseline. A composite of stroke/transient ischemic attack (TIA), thromboembolic events, major bleeding, and death was the primary endpoint. Stroke/TIA, thromboembolic events and major bleeding, presence of AF, new onset of heart failure and change of NYHA class, and bradyarrhythmia necessitating pacemaker implantation were secondary endpoints.

Results

Patients (age 92 ± 2.7 years, range 89–108) presented in EHRA class I in 38.4% of the cases, class II in 49.5%, class III in 10%, and class IV in 2%. Rhythm control was attempted in 37 (13.3%) of the patients. Baseline CHA2DS2-VASc and HAS-BLED were 5.0 ± 1.3 and 3.1 ± 0.9, respectively. Oral anticoagulation (OAC) was initiated in 74 (26.5 %) of the patients. Of all patients, 33 (11.8%) patients died in hospital. Of the remaining patients, 104 were followed over 13.8 ± 17.5 months with 3.5 ± 2.3 visits during follow-up. Rhythm control was attempted in 10 patients (9.6%). OAC was initiated in 37 patients (35.6 %). Fifty-nine (56.7%) patients reached the primary composite endpoint. Stroke/TIA (34.6%) and heart failure (49%) were common. Subgroup analysis revealed no significant differences in any of the endpoints between patients undergoing rhythm versus rate control and between patients under OAC compared with patients without OAC. INR at follow-up and TTR were 1.76 ± 1.0 and 29.5% ± 37.8% in patients receiving VKA.

Conclusion

In this real-world cohort of very elderly patients with AF, a rhythm control strategy and OAC treatment were chosen only in a minority of the cases. If OAC was initiated, most received VKAs with a poor TTR during follow-up. A high incidence of stroke/TIA was observed in patients with and without OAC. Further data are needed to define optimal treatment of AF in this particular patient group.

Section snippets

Methods

From a local database (the Berlin Atrial Fibrillation [BAF] database) all patients aged 89 years or older were identified. The BAF database consists of 11,888 patients who presented to our university hospital center with AF between January 2001 and December 2014. Patients with hyperthyroidism, shock of any type, sepsis, known end-stage malignant disease, or severe trauma were excluded from the registry. The study complies with the Declaration of Helsinki and was approved by the ethics committee

Baseline Results

Of all patients who presented to our hospital center and were included in the BAF registry between January 2001 and December 2014 (n = 11,888), 279 (2.3 %) were 89 years or older.

Mean age was 92.0 ± 2.7 years (range 89–108); characteristics are presented in Table 1. Patients' baseline medication is listed in Table 2.

Of all patients, 17.2% had first-diagnosed AF, 42.3% had paroxysmal AF, 9% had persistent AF, and 31.5% permanent AF. Patients initially presented with EHRA class I in 38.4% of the

Discussion

Here we present the results of a study on the treatment and outcomes of AF in nonagenarians. Our data show a proportion of 2.3% of patients who presented between 2001 and 2014 and were included in the BAF registry who were 89 years or older.

Among those, most (61.6 %) was symptomatic. Rate control was chosen as a treatment strategy in most of the cases (86.7%), although roughly two-thirds of the patients had paroxysmal or even first-diagnosed AF. The presence of relevant comorbidities and

Conclusion

The main treatment strategy for AF in nonagenarians is rate control. OAC is generally underused in nonagenarians and in most cases VKAs are used. The rate of stroke and TIA is high in both patients without and with OAC. The latter is most likely a consequence of a very low TTR. Future studies should focus on improvement of INR monitoring in nonagenarians and the efficacy and safety of DOACs in this age group.

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The authors declare no conflicts of interest.

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Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.