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Oral anticoagulation (OAC) is effective in stroke prevention in elderly patients with nonvalvular atrial fibrillation (AF), but older patients are also at higher risk of bleeding.We aimed to examine whether OAC has net clinical benefit (NCB) in elderly patients with AF.This is a retrospective cohort study of patients with AF, aged 75 years and older, who were diagnosed from January 1, 2013, through December 31, 2015. Incidences of stroke and intracranial hemorrhage (ICH) were estimated as the number of events per 100 person-years. The NCBs were estimated with respect to time in therapeutic range (TTR) (60% or ≥60%) and treatment type (warfarin and low or high dose of direct oral anticoagulants [DOACs]).We included 11,760 patients, of whom 4982 (42.4%) were treated with OACs: 2042 (17.4%) with warfarin and 2940 (25.0%) with DOACs. Among patients treated with warfarin, those who achieved TTR ≥ 60% had a lower incidence of stroke (2.54 per 100 person-years vs 5.21 per 100 person-years; P = .01) but without a statistically significant lower incidence of ICH (0.68 per 100 person-years vs 1.10 per 100 person-years; P = .45) and a higher NCB (9.78 vs 6.52) than did those with TTR60%. Among patients treated with DOACs, patients treated with the high dose had a statistically significant similar incidence of stroke (8.40 per 100 person-years vs 9.81 per 100 person-years; P = .67), a statistically significant lower incidence of ICH (0.33 per 100 person-years vs 1.20 per 100 person-years; P = .02), and a higher NCB (4.42 vs 1.78) than did patients treated with the low dose.A large proportion of elderly patients are not treated with OACs. We found that the NCB of OAC in the elderly is positive, with the highest benefit in elderly patients treated with warfarin who achieved TTR ≥ 60% or high dose of DOACs.

Elderly patients are underrepresented in clinical trials of device therapy.To provide real-world data regarding outcomes associated with device-based therapy in a large cohort of elderly patients enrolled in the Israeli ICD Registry.Between July 2010 and June 2012, a total of 2807 consecutive patients undergoing implanted cardioverter-defibrillator/cardiac resynchronization therapy-defibrillator (ICD/CRT-D) implantation were prospectively enrolled in the Israeli ICD Registry. For the present analysis, patients were categorized into 3 age groups: ≤60 years (n = 1378 [49%]), 61-75 years (n = 863 [31%]), and75 years (n = 566 [20%]).Elderly patients (75 years of age) had more comorbid conditions and were more likely to undergo CRT-D implantation (all P.01). However, the rate of device-related complications associated with surgical reinterventions at 1 year was3% regardless of age (P = .70 for the comparison among the 3 age groups). Multivariate analysis showed that the risk of heart failure or death and of appropriate ICD therapy for ventricular arrhythmias was significantly increased with increasing age among patients who received an ICD. In contrast, the age-related increase in the risk of all end points was attenuated among patients who received CRT-D devices (all P values for age-by-device-type interactions are.05).In a real-world scenario, elderly patients (75 years of age) comprise approximately 20% of the ICD/CRT-D recipients and experience a device reintervention rate similar to that of their younger counterparts. Our data suggest that the association between advanced age and adverse clinical outcomes is attenuated in elderly patients implanted with CRT-D devices.

Background Defibrillation threshold (DFT) testing during placement of an implantable cardioverter-defibrillator (ICD) has been considered mandatory. Accumulating data suggest a more limited role for DFT. Objective The purpose of this study was to compare the outcome of ICD recipients who underwent DFT testing compared with those who did not. Methods In this prospective cohort analysis of patients who received an ICD between July 2010 and March 2013, we compared patients who underwent DFT testing and those who did not. Primary end-points were death and malignant ventricular arrhythmias. Secondary end-points included the composite end-points and inappropriate ICD discharges. Results Of the 3596 patients in the registry, 614 patients (17%) underwent DFT testing during ICD placement vs 2982 (83%) who did not. Variables associated with ICD testing were implantation for secondary prevention (relative risk [RR] 1.87), prior ventricular arrhythmias (RR 1.81), use of antiarrhythmic medication (RR 1.59), and sinus rhythm (RR 2.05). Factors predisposing against testing were cardiac resynchronization therapy defibrillator implantation (RR 0.56) and concomitant diuretic use (RR 0.71). ICD testing was not associated with 1-year mortality (5.3% vs 5.1%, P = .74), delivery of appropriate shocks (8.6% vs 5.6%, P = .16), combined outcomes of ventricular arrhythmias and death (12.9% vs 11.3%, P = .45), or inappropriate ICD discharges (3.9% vs 2.1%, P = .2) compared to no DFT testing. Conclusion No significant differences in the incidence of mortality, malignant ventricular arrhythmias, or inappropriate ICD discharges were observed between patients who underwent DFT testing compared to those who did not. Our results may support avoiding DFT testing during ICD placement, but this requires confirmation by additional prospective studies.

Three-dimensional rotational atriography (3DATG) was developed to supplement two-dimensional fluoroscopy with 3D volume reconstruction of the left atrium (LA), pulmonary veins (PV), and other structures. Until recently, 3DATG images could only be viewed separately and were not suitable to directly guide atrial fibrillation (AF) ablation.The purpose of this study was to evaluate the feasibility and accuracy of intraprocedural 3DATG.Three-dimensional rotational atriography with right atrial contrast injection was obtained using a Philips Allura Xper FD10 system in 30 patients with symptomatic AF who also underwent preprocedural computed tomographic (CT) scan.The majority (93%) of 3DATG image reconstructions were useful for guidance of catheter ablation. Nearly all PVs (94%), LA appendage (89%), and esophagus (100%) were successfully segmented. Measured PV ostial diameters compared using 3DATG and CT showed close concordance. Registration and re-registration of 3DATG overlay image was easily achieved with thoracic landmarks and validated by catheter placement demonstrating minimal discrepancy. Endoscopic views allowed for improved visualization of ostial position, dimensions, and navigation within the antrum. Lesion tagging on 3DATG overlay enhanced ablation guidance. Radiation exposure with 3DATG was significantly reduced compared with preprocedural CT scan (2.1 +/- 0.3 mSv vs 13.8 +/- 2.4 mSv, P.001).Intraprocedural 3DATG imaging during AF ablation with online segmentation and superimposition on live fluoroscopy is feasible. Overlay provides valuable and accurate information on 3D surface outline and endoscopic PV location. Three-dimensional rotational atriography overlay is a new imaging method with reduced radiation exposure that may replace preprocedural CT scan for catheter navigation and ablation of AF.