Heart Rhythm Disorders in Older Adults

Heart Rhythm Disordersin Older AdultsMichael W Rich, MDProfessor of MedicineWashington University School of MedicineSt. Louis, MissouriDisclosures: NoneOutlineEffects of aging on the cardiac conduction systemBradyarrhythmias and pacemakersSupraventricular arrhythmias: Focus on atrial fibrillationVentricular arrhythmias: Focus on ICDsResearch directions: Unmet needsEffects of Aging on the Cardiac Conduction SystemSinus nodeProgressive decline in number of pacemaker cells ( 75 yrs(N=385) all-cause CVA withresidual deficit occurred in4.6% of pts on warfarinvs. 4.3% of pts on aspirin.BAFTA: Subgroup AnalysisLancet 2007;370:493-503

Incidence of Major Extracranial Bleeding in 13,559 Patients with Atrial FibrillationJ Am Geriatr Soc 2006;54:1231-1236

Incidence of Intracranial Hemorrhage in 13,559 Patients with Atrial Fibrillation

J Am Geriatr Soc 2006;54:1231-1236Risk of Major Bleeding Events in Patients at High vs. Low Risk for Falls

Am J Med 2012;125:773-8Prospective study of 515 pts on oral anticoagulantsMedian 71.2 yrs, 64% maleHigh fall risk: 59.8%Follow-up: 12 moIncidence of major bleeds: 7.5 per 100 pt-yrsPredictors of major bleeds: female, # of medications

AHR: 1.09 (o.54-2.21)In NVAF, what may matter most topatients is not the risk of stroke or bleeding but rather the risks of functional and cognitive disability.Arch Intern Med 2010;170:566-569Emerging Therapies for Atrial FibrillationDronedarone - ATHENA: N Engl J Med 2009;360:668-78- Similar results in pts < 75 and 75Dabigatron (direct thrombin inhibitor)- RE-LY: N Engl J Med 2009;361:1139-51- No subgroup analysis by ageAspirin + clopidogrel (vs. aspirin alone)- ACTIVE-A: N Engl J Med 2009; 360:2066-78- No benefit in pts 75

ACTIVE-A Study Design7554 pts with AF, increased stroke risk, and contraindications to vitamin K antagonistsMean age 71 yrs, 42% female, mean CHADS2 score 2.0Randomized to ASA 75-100 mg/day plus either clopidogrel 75 mg/day or placebo (double-blind)Primary endpoint: CV death, stroke, MI, systemic embolismMedian follow-up 3.6 yearsNEJM 2009;360:2066-78ACTIVE-A: Primary ResultsNEJM 2009;360:2066-78

RR 0.89, P=0.01ACTIVE-A: StrokeNEJM 2009;360:2066-78

RR 0.72, P 30%NEJM 2005;352:225-37ICD vs. Placebo in Selected Subgroups: SCD-HeFT

All-Cause Mortality: SCD-HeFTICD vs. Amiodarone vs. PlaceboNEJM 2005;352:225-37ICDPlaceboAmio74Figure 1. Kaplan-Meier Estimates of Death from Any Cause. CI denotes confidence interval.ECG Manifestations of Sinus Node Dysfunction