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Objectives: To determine the effect of new oral anticoagulants (NOACs) on prescribing practices in older adults with atrial fibrillation (AF)., Design: Retrospective observational cohort study., Setting: Academic medical center in St. Louis, Missouri., Participants: Individuals aged 75 and older with AF admitted to the hospital from October 2010 through September 2015 (N = 6,568, 50% female, 15% non-white)., Measurements: Information on NOACs and warfarin prescribed at discharge was obtained from hospital discharge summaries, and linear regression was used to examine quarterly trends in their use. Multivariable logistic regression was used to assess independent predictors of anticoagulant use., Results: NOAC use increased over time (correlation coefficient (r) = 0.87, P < .001), warfarin use did not change (r = -0.16, P = .50), and overall anticoagulant use (NOACs and warfarin) increased (r = 0.68, P = .001). NOAC use increased over time in all age groups (75-79, 80-84, 85-89) except aged 90 and older, but increasing age attenuated the rate of NOAC uptake. There was no consistent relationship between age and warfarin or overall anticoagulant use, except that individuals aged 90 and older had consistently lower use. Overall, fewer than 45% of participants were prescribed an anticoagulant. In multivariable analysis, younger age, white race, female sex, higher hemoglobin, higher creatinine clearance, being on a medical service, hypertension, stroke or transient ischemic attack, no history of intracranial hemorrhage, and a modified HAS-BLED score of less than 3 increased the likelihood of receiving NOACs., Conclusion: Prescription of anticoagulants for AF increased in older adults primarily because of an increase in the use of NOACs. Nonetheless, fewer than 45% of participants were prescribed an anticoagulant. Additional research is needed to optimize prescribing practices for older adults with AF., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Guidelines for managing atrial fibrillation recommend systemic anticoagulation for almost all patients age 65 and older, but in practice up to 50% of older patients do not receive maintenance anticoagulation therapy. The most common reason physicians cite for withholding anticoagulation in older patients with atrial fibrillation is a perception of a high risk of falling and associated bleeding, especially intracranial hemorrhage., (Copyright © 2017 Cleveland Clinic.)

Background: The prevalence of atrial fibrillation substantially increases after 70 years of age. However, the effect of rate-control versus rhythm-control strategies on outcomes in these patients remains unclear., Methods: In the randomized Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial, 4060 patients (mean age 70 years, range 49-80 years) with paroxysmal and persistent atrial fibrillation were randomized to rate-control versus rhythm-control strategies. Of these, 2248 were 70-80 years, of whom 1118 were in the rate-control group. Propensity scores for rate-control strategy were estimated for each of the 2248 patients and were used to assemble a cohort of 937 pairs of patients receiving rate-control versus rhythm-control strategies, balanced on 45 baseline characteristics., Results: Matched patients had a mean age of 75 years; 45% were women, 7% were nonwhite, and 47% had prior hospitalizations due to arrhythmias. During 3.4 years of mean follow-up, all-cause mortality occurred in 18% and 23% of matched patients in the rate-control and rhythm-control groups, respectively (hazard ratio [HR] associated with rate control, 0.77; 95% confidence interval [CI], 0.63-0.94; P = .010). HRs (95% CIs) for cardiovascular and noncardiovascular mortality associated with rate control were 0.88 (0.65-1.18) and 0.62 (0.46-0.84), respectively. All-cause hospitalization occurred in 61% and 68% of rate-control and rhythm-control patients, respectively (HR 0.76; 95% CI, 0.68-0.86). HRs (95% CIs) for cardiovascular and noncardiovascular hospitalization were 0.66 (0.56-0.77) and 1.07 (0.91-1.27), respectively., Conclusion: In septuagenarian patients with atrial fibrillation, compared with rhythm-control, a rate-control strategy was associated with significantly lower mortality and hospitalization., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Increasing age is a potent risk factor for the development of atrial fibrillation (AF), as well as for incident stroke in patients with AF. The prevalence of AF in long term care facilities ranges from 7.5% to 17%, and such patients often present management challenges due to heightened risk for both stroke and bleeding complications related to thromboprophylaxis. This article reviews the diagnosis and management of AF in long term care. In general, patients with minimal symptoms can be managed with rate-control medications and anticoagulation. Patients with persistent symptoms and impaired quality of life despite adequate rate-control should be considered for cardioversion and antiarrhythmic drug therapy aimed at maintaining sinus rhythm. A small percentage of patients who do not respond to rate-control or rhythm-control interventions may be candidates for a catheter-based or surgical ablative procedure. In most older adults, the benefits of systemic anticoagulation in reducing the risk of stroke outweigh the risk of serious bleeding; therefore, anticoagulation is indicated in the majority of older AF patients, including nursing home residents. Although warfarin remains the preferred agent for stroke prophylaxis in the long term care setting, primarily due to very limited experience with the newer agents dabigatran, rivaroxaban, and apixaban, it is likely that the use of these newer drugs will increase as additional data accumulate documenting their safety and efficacy in AF patients of advanced age., (Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

The incidence and prevalence of atrial fibrillation (AF) increase progressively with age, and approximately 50% of patients with AF are 75 years of age or older. Advanced age is also a potent risk factor for stroke in patients with AF, and the proportion of strokes attributable to AF increases exponentially with age. In addition, AF contributes incrementally to health care utilization and costs, and decrementally to survival and quality of life in older adults. Furthermore, the societal impact of AF will likely double over the next three decades due to the aging of the population. For these reasons, it is essential to develop more effective strategies for the prevention and treatment of AF in older individuals.

Background: Anemia and atrial fibrillation (AF) are common among the elderly. Anemia is an independent predictor of mortality and morbidity for numerous cardiovascular and noncardiovascular diseases, but the association of anemia with mortality and hospitalizations in patients with AF requires clarification., Methods: Subjects were 13,067 Medicare beneficiaries hospitalized with AF and included in the National Registry of Atrial Fibrillation II data set. Index hospitalization hematocrit (Hct) was obtained by structured chart abstraction. Cox proportional hazards models quantified the association of Hct with mortality and re-hospitalizations during a median follow-up period of 12 months., Results: The mean age was 79.8 years, 58% were women, and the mean Hct was 39.2%. Hematocrit was significantly (P < .0001) associated with risk of death and of rehospitalization even after adjustment for demographic information, comorbid conditions, and use of cardiovascular medications. As compared to a Hct of 40% to 44.9%, the adjusted hazard ratios for mortality were 1.66 for Hct <25%, 1.50 for 25% to 29.9%, 1.28 for 30% to 34.9%, 1.07 for 35% to 39.9%, 1.03 for 45% to 49.9%, and 1.10 for > or = 50%. The association between anemia and mortality was significant in men and women but stronger in men (P = .006 for interaction). Compared to the category 40% to 44.9%, the risk of rehospitalization was increased to 28% (adjusted hazard ratio 1.28, 95% CI 1.15-1.43) in the Hct category 25% to 29.9%., Conclusion: Anemia is an independent predictor of mortality and of hospitalizations in elderly patients with AF. Studies are needed to assess the effect of treatment of anemia on clinical outcomes.

Atrial fibrillation is increasingly prevalent among older adults. It causes approximately 24% of strokes in patients aged 80 to 89 years. The management of atrial fibrillation is directed at preventing thromboembolism and controlling the heart rate and rhythm. Stroke prevention is most effectively accomplished through administering anticoagulants such as warfarin, although older patients have higher hemorrhagic risk. Cognitive dysfunction, functional impairments, and increased fall risk further complicate warfarin management in elderly patients. The use of risk stratification schemes can help guide the anticoagulation decision, although the benefits of warfarin generally outweigh the risks in most older patients with atrial fibrillation. Pharmacologic rate control has been shown to result in similar outcomes compared with pharmacologic restoration of sinus rhythm and should be the initial therapy for elderly patients. Anti-arrhythmic medications should be selected based on an individual patient's coexisting medical conditions. In symptomatic patients who fail pharmacologic therapy, invasive strategies such as AV nodal ablation may help improve quality of life and symptoms, although such strategies do not obviate the need for antithrombotic therapy.

Background: Although warfarin and other anticoagulants can prevent ischemic events, they can cause hemorrhage. Quantifying the rate of hemorrhage is crucial for determining the risks and net benefits of prescribing antithrombotic therapy. Our objective was to find a bleeding classification scheme that could quantify the risk of hemorrhage in elderly patients with atrial fibrillation., Methods: We combined bleeding risk factors from existing classification schemes into a new scheme, HEMORR2HAGES, and validated all bleeding classification schemes. We scored HEMORR2HAGES by adding 2 points for a prior bleed and 1 point for each of the other risk factors: hepatic or renal disease, ethanol abuse, malignancy, older (age > 75 years), reduced platelet count or function, hypertension (uncontrolled), anemia, genetic factors, excessive fall risk, and stroke. We used data from quality improvement organizations representing 7 states to assemble a registry of 3791 Medicare beneficiaries with atrial fibrillation., Results: There were 162 hospital admissions with an International Classification of Diseases, Ninth Revision, Clinical Modification code for hemorrhage. With each additional point, the rate of bleeding per 100 patient-years of warfarin increased: 1.9 for 0, 2.5 for 1, 5.3 for 2, 8.4 for 3, 10.4 for 4, and 12.3 for > or =5 points. In patients prescribed warfarin, HEMORR2HAGES had greater predictive accuracy (c statistic 0.67) than other bleed prediction schemes (P < .001)., Conclusions: Adaptations of existing classification schemes, especially a new bleeding risk scheme, HEMORR2HAGES, can quantify the risk of hemorrhage and aid in the management of antithrombotic therapy.

Purpose: Patients at high risk for falls are presumed to be at increased risk for intracranial hemorrhage, and high risk for falls is cited as a contraindication to antithrombotic therapy. Data substantiating this concern are lacking., Methods: Quality improvement organizations identified 1245 Medicare beneficiaries who were documented in the medical record to be at high risk of falls and 18261 other patients with atrial fibrillation. The patients were elderly (mean 80 years), and 48% were prescribed warfarin at hospital discharge. The primary endpoint was subsequent hospitalization for an intracranial hemorrhage, based on ICD-9 codes., Results: Rates (95% confidence interval [CI]) of intracranial hemorrhage per 100 patient-years were 2.8 (1.9-4.1) in patients at high risk for falls and 1.1 (1.0-1.3) in other patients. Rates (95% CI) of traumatic intracranial hemorrhage were 2.0 (1.3-3.1) in patients at high risk for falls and 0.34 (0.27-0.45) in other patients. Hazard ratios (95% CI) of other independent risk factors for intracranial hemorrhage were 1.4 (1.0-3.1) for neuropsychiatric disease, 2.1 (1.6-2.7) for prior stroke, and 1.9 (1.4-2.4) for prior major bleeding. Warfarin prescription was associated with intracranial hemorrhage mortality but not with intracranial hemorrhage occurrence. Ischemic stroke rates per 100 patient-years were 13.7 in patients at high risk for falls and 6.9 in other patients. Warfarin prescription in patients prone to fall who had atrial fibrillation and multiple additional stroke risk factors appeared to protect against a composite endpoint of stroke, intracranial hemorrhage, myocardial infarction, and death., Conclusion: Patients at high risk for falls with atrial fibrillation are at substantially increased risk of intracranial hemorrhage, especially traumatic intracranial hemorrhage. However, because of their high stroke rate, they appear to benefit from anticoagulant therapy if they have multiple stroke risk factors.

Reports results from the National Registry of Atrial Fibrillation on the validation of clinical classification schemes for predicting stroke. Risk prediction factors including age, coronary artery disease and congestive heart failure; The combination of two existing classification schemes into a new stroke-risk scheme; Stroke rates of various demographics; Results; Conclusions.