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STUDY OBJECTIVES: Geriatric impairments and obstructive sleep apnea (OSA) are prevalent among older patients with atrial fibrillation (AF). Little is known about the association between OSA and geriatric impairments, including frailty, cognitive performance, and AF-related quality of life. The objective of this study was to examine the associations of OSA with frailty, cognitive performance, and AF-related quality of life among older adults with AF. METHODS: Data from the Systemic Assessment of Geriatrics Elements-AF study were used, which included AF participants 65 years and older and with a CHA(2)DS(2)-VASc ≥ 2. The STOP-BANG questionnaire was used to assess the risk of OSA. Multivariable logistic regression models were used to examine the association between risk of OSA and geriatric impairments, adjusting for sociodemographic, geriatric, and clinical characteristics. RESULTS: A total of 970 participants (mean age 75 years; 51% male) were studied. Of the 680 participants without a medical history of OSA, 26% (n = 179) of participants had a low risk of OSA, 53% (n = 360) had an intermediate risk, and 21% (n = 141) had a high risk for OSA. Compared to those with low risk of OSA, participants with an intermediate or high risk of OSA were more likely to be frail (adjusted odds ratio = 1.67, 95% confidence interval: 1.08–2.56; adjusted odds ratio = 3.00, 95% confidence interval: 1.69–5.32, respectively) in the fully adjusted models. CONCLUSIONS: Our findings identify a group of patients at high risk who would benefit from early screening for OSA. Future longitudinal studies are needed to assess the effect of OSA treatment on frailty, physical functioning, and quality of life among patients with AF. CITATION: Mehawej J, Saczynski JS, Kiefe CI, et al. Association between risk of obstructive sleep apnea and cognitive performance, frailty, and quality of life among older adults with atrial fibrillation. J Clin Sleep Med. 2022;18(2):469–475.

Background Telemedicine and commercial wearable devices capable of detecting atrial fibrillation (AF) have revolutionized arrhythmia care during coronavirus disease 2019. However, not much is known about virtual patient-provider interactions or device sharing behaviors. Objective The purpose of this study was to characterize how participants with or at risk of AF are engaging with their providers in the context of telemedicine and using commercially wearable devices to manage their health. Methods We developed a survey to describe participant behaviors around telemedicine encounters and commercial wearable device use. The survey was distributed to participants diagnosed with AF or those at risk of AF (as determined by being at least 65 years old and having a CHA2DS2-VASc stroke risk score of >2) in the University of Massachusetts Memorial Health Care system. Results The survey was distributed to 23,530 patients, and there were 1222 (5.19%) participant responses. Among the participants, 327 (26.8%) had AF and 895 (73.2%) were at risk of AF. Neither device ownership nor device type use differed by AF status. After adjusting for covariates that may influence surveyed participant communication patterns, we found that participants with AF were more likely to share their wearable device-derived data with providers (adjusted odds ratio 1.87; 95% confidence interval 1.02–3.41). Rates of sharing physical activity or sleep data were low for both groups and did not differ by AF status. Conclusion Compared with participants at risk of developing AF, those with AF were more likely to share heart rate and rhythm data from their commercial wearable devices with providers. However, both groups had similar rates of sharing physical activity and sleep data, telemedicine engagement, and technology use and ownership.

Background Atrial fibrillation (AF) commonly occurs in the setting of acute conditions. We aimed to identify the acute conditions associated with secondary AF (AF precipitants) including pneumonia/sepsis, pneumothorax, respiratory failure, myocarditis, pericarditis, alcohol intoxication, thyrotoxicosis, cardiothoracic surgery, other surgery in patients with newly diagnosed AF and determine their association with subsequent oral anticoagulant use. Methods and Results We assembled a cohort of patients in the UMass Memorial Healthcare system with a new diagnosis of AF with and without AF precipitants. We used combinations of International Classification of Diseases , Tenth Revision ( ICD‐10 ) codes, Current Procedural Terminology codes, laboratory values, imaging reports, and physician notes including discharge summary texts to identify AF precipitants. We then manually reviewed the individual charts to validate presence of AF precipitants. The study sample consisted of 185 patients with and 172 patients without AF precipitants. Pneumonia/sepsis, myocardial infarction, respiratory failure, and cardiothoracic surgery were the most common precipitants identified. In multivariable analyses adjusting for age, sex, patient comorbidities, left atrial enlargement, left ventricular ejection fraction, and antiplatelet use, patients with AF precipitants were less likely to receive subsequent anticoagulation therapy at 30 days after the initial AF diagnosis (odds ratio, 0.31; 95% CI, 0.19–0.52). The association was persistent after excluding men with CHA 2 DS 2 ‐VASc score 2 DS 2 ‐VASc score Conclusions Our study highlights lower usage of oral anticoagulant in secondary AF in contemporary clinical practice.

Objective: Guidelines encourage patients with atrial fibrillation (AF) to engage in moderate-intensity physical activity. We examined the sociodemographic, geriatric, and clinical factors associated with engagement in moderate-intensity physical activity among older adults with AF. Methods: Patients aged 65 years and older, diagnosed with AF, and having a CHA 2 DS 2 -VASc ≥ 2 were recruited from multiple clinics in Massachusetts and Georgia between 2015 and 2018. We utilized The Minnesota Leisure Time Physical Activity questionnaire to assess whether participants reported being engaged in moderate physical exercise. We examined the association between sociodemographic, clinical, geriatric elements and engaging in moderate-intensity physical activity using multiple logistic regression modelling. Results: The mean age of participants was 76 years and 52% were men. Approximately one-half (52%) of participants met the recommended levels of physical activity. Participants who were cognitively impaired (adjusted OR [aOR]=0.74; 95% CI= 0.56-0.97 ) , morbidly obese (aOR= 0.40; 95% CI= 0.22-0.72), socially isolated (aOR= 0.58; 95% CI= 0.40-0.84), and had a slow gait speed (aOR= 0.44; 95% CI= 0.32-0.60) were less likely, while those with higher AF related quality of life score (aOR=1.66; 95% CI=1.26-2.18) more likely, to engage in moderate physical activity. Conclusions: A considerable proportion of older adults with AF did not engage in moderate physical activity. Cognitive impairment, morbid obesity, social isolation, and slow gait speed were associated with not engaging in moderate exercise. Health care providers should identify patients with AF who are sedentary, promote engagement, and tailor interventions to address obstacles in engagement in physical activity.

OBJECTIVE: Engaging patients with atrial fibrillation (AF) in moderate-intensity physical activity has been encouraged by published guidelines. We examined factors associated with engagement in moderate physical activity among older adults with AF. METHODS: This was a retrospective study involving ninety patients with episodes of Afib with RVR duData are from the SAGE (Systematic Assessment of Geriatric Elements)-AF study. Older adults (≥ 65 years) with AF and a CHA(2)DS(2)-VASc ≥ 2 were recruited from several clinics in Massachusetts and Georgia between 2015 and 2018. The Minnesota Leisure Time Physical Activity questionnaire was used to assess whether participants engaged in moderate-intensity physical activity (i.e. at least 150 minutes of moderate exercise). Logistic regression was utilized to examine the sociodemographic and clinical characteristics and geriatric elements associated with engaging in moderate-intensity physical activity. RESULTS: Participants were on average 76 years old and 48% were women. Approximately one-half (52%) of study participants engaged in moderate-intensity physical activity. Morbid obesity (adjusted OR [aOR]=0.41, 90%CI=0.23-0.73), medical history of renal disease (aOR= aOR=0.68,90%CI= 0.48-0.96), slow gait speed (aOR=0.44, 90%CI=0.32-0.60), cognitive impairment (aOR=0.74, 90%CI=0.56-0.97), and social isolation (aOR=0.58, 90%CI= 0.40-0.84) were independently associated with a lower likelihood, while higher AF related quality of life score (aOR=1.64, 90%CI=1.25-2.16) a greater likelihood, of meeting recommended levels of moderate physical activity. CONCLUSIONS: Nearly one-half of older adults with NVAF did not engage in moderate-intensity exercise. Clinicians should identify older patients with NVAF who are less likely to engage in physical activity and develop tailored interventions to promote regular physical activity.

Introduction: Atrial fibrillation (AF) that is associated with acute precipitants frequently recurs and is associated with long-term morbidity and mortality. Leveraging a large electronic medical record (EMR) database, we previously reported the performance of an automated EMR-based algorithm to identify the acute precipitants of newly detected-AF, but its validation in other databases has not been performed. Hypothesis: Modified EMR-based algorithm would accurately identify acute precipitants of AF and oral anticoagulation (OAC) use after AF diagnosis Methods: Among all records (inpatient/outpatient/ER) in a single-institution EMR (10/1/17 - 12/31/19), we first identified 4493 records documenting newly-diagnosed AF (ICD 10: I48). We then applied the modified EMR-based algorithm to identify 13 acute AF precipitants (within 30 days of AF diagnosis, Figure 1) and determine OAC use after an AF diagnosis. We manually adjudicated a random subset of identified records (892 of 4493) to derive performance metrics of the EMR algorithm. Results: Of 4493 records with newly-diagnosed AF, the algorithm identified ≥1 acute precipitant in 831 records and ≥2 precipitants in 206 records. The most common precipitants were respiratory failure (38%) and pneumonia (35%). Among patients with CHADS2Vasc ≥2, 44% with an acute precipitant were prescribed an OAC vs. 63% free from a precipitant after initial AF diagnosis. EMR algorithm accurately identified the precipitants and OAC use after AF diagnosis (PPV 89% for both, Figure 1). Conclusions: In this validation study, our novel EMR-based automated algorithm was highly accurate at identifying acute precipitants of AF and OAC use after AF diagnosis. We also observed differential rates of OAC use between those with and without an acute precipitant. Application of the algorithm to multi-institutional datasets could help map the gaps in care (e.g., OAC use) AF patients with acute precipitants often experience.

Introduction: Though engaging patients with atrial fibrillation (AF) in the decision-making process for stroke prevention is encouraged by guidelines, little is known about the extent of, and the factors associated with, patient engagement in this process. Hypothesis: Patient engagement in shared decision-making (SDM) would be modest and that older participants will less likely engage in SDM for stroke prevention. Methods: Data are from the ongoing SAGE (Systematic Assessment of Geriatric Elements)-AF study which enrolled older adults aged 65 years and older with AF from clinics in Massachusetts and Georgia. Participants on an oral anticoagulant (OAC) reported whether they were engaged in the decision to be on an OAC by answering “Yes” to the question: “Did you participate actively in choosing to take an OAC?”. We used multiple logistic regression analysis to examine the sociodemographic, geriatric, psychosocial, and clinical factors associated with patient engagement in SDM for stroke prevention. Results: Participants (N= 807) were on average 75 years old and 48% were female. Approximately, 61% engaged in the decision to be on an OAC. Participants aged 80 years and older (aOR= 0.53; 95 % CI:0.31-0.89) and those cognitively impaired (aOR= 0.69; 95 % CI: 0.48, 0.99) were less likely to engage in SDM than respective comparison groups. Participants who reported being very knowledgeable of their AF associated risk of stroke had higher odds of engaging in SDM than those with less knowledge (aOR= 3.06; 95 % CI:1.59, 5.90). Conclusions: Clinicians should identify older patients and those who are cognitively impaired who are less likely to engage in SDM for stroke prevention, promote patient engagement, and provide support to ensure sustained engagement that would enhance long-term treatment outcomes for patients with AF.

Background Though engaging patients with atrial fibrillation (AF) in understanding their stroke risk is encouraged by guidelines, little is known regarding AF patients' perceived stroke risk or its relationship with oral anticoagulation (OAC) use. We aim to identify factors associated with underestimation of stroke risk among older patients with AF and relate this to OAC use. Methods Data are from the ongoing SAGE (Systematic Assessment of Geriatric Elements)-AF study, which included older patients (> 65 years) with non-valvular AF and a CHA2DS2-VASc score of ≥ 2. Participants reported their perceived risk of having a stroke without OAC. We compared the perceived risk to CHA2DS2-VASc predicted stroke risk and classified participants as "over" or "under" estimators, and identified factors associated with underestimation of risk using multiple logistic regression. Results The average CHA2DS2-VASc score of 915 participants (average age: 75 years, 47% female, 86% white) was 4.3 ± 1.6, 43% of participants had discordant predicted and self-reported stroke risks. Among the 376 participants at highest risk (CHA2DS2-VASc score ≥ 5), 46% of participants underestimated their risk. Older participants (≥ 85 years) were more likely and OAC treated patients less likely to underestimate their risk of developing a future stroke than respective comparison groups. Conclusions A significant proportion of study participants misperceived their stroke risk, mostly by overestimating. Almost half of participants at high risk of stroke underestimated their risk, with older patients more likely to do so. Patients on OAC were less likely to underestimate their risk, suggesting that successful efforts to educate patients about their stroke risk may influence treatment choices.