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Review
. 2016 Sep 22;11(1):e41-e49.
doi: 10.5301/heartint.5000230. eCollection 2016 Jan-Dec.

Atrial fibrillation management in older heart failure patients: a complex clinical problem

Giovanni Pulignano  1 , Donatella Del Sindaco  2 , Maria Denitza Tinti  1 , Stefano Tolone  1 , Giovanni Minardi  1 , Antonio Lax  2 , Massimo Uguccioni  1
Affiliations
Review

Atrial fibrillation management in older heart failure patients: a complex clinical problem

Giovanni Pulignano et al. Heart Int. .

Abstract

Background: Atrial fibrillation (AF) and heart failure (HF), two problems of growing prevalence as a consequence of the ageing population, are associated with high morbidity, mortality, and healthcare costs. AF and HF also share common risk factors and pathophysiologic processes such as hypertension, diabetes mellitus, ischemic heart disease, and valvular heart disease often occur together. Although elderly patients with both HF and AF are affected by worse symptoms and poorer prognosis, there is a paucity of data on appropriate management of these patients.

Methods: PubMed was searched for studies on AF and older patients using the terms atrial fibrillation, elderly, heart failure, cognitive impairment, frailty, stroke, and anticoagulants.

Results: The clinical picture of HF patients with AF is complex and heterogeneous with a higher prevalence of frailty, cognitive impairment, and disability. Because of the association of mental and physical impairment to non-administration of oral anticoagulants (OACs), screening for these simple variables in clinical practice may allow better strategies for intervention in this high-risk population. Since novel direct OACs (NOACs) have a more favorable risk-benefit profile, they may be preferable to vitamin K antagonists (VKAs) in many frail elderly patients, especially those at higher risk of falls. Moreover, NOACs are simple to administer and monitor and may be associated with better adherence and safety in patients with cognitive deficits and mobility impairments.

Conclusions: Large multicenter longitudinal studies are needed to examine the effects of VKAs and NOACs on long-term cognitive function and frailty; future studies should include geriatric conditions.

Keywords: Atrial fibrillation; Cognitive impairments; Elderly; Frailty; Heart failure; Oral anticoagulants.

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Conflict of interest statement

None of the authors has financial interest related to this study to disclose.

Figures

Fig. 1 -
Fig. 1 -
Common pathophysiological mechanisms and interactions between atrial fibrillation (AF) and heart failure (HF). LA = left atrium; MR = mitral regurgitation; TR = tricuspid regurgitation.
Fig. 2 -
Fig. 2 -
The effect of apixaban versus warfarin on major study outcomes according to age in the ARISTOTLE study. *Interaction p values are based on continuous age. Modified from (25): Halvorsen S, Atar D, Yang H, et al. Efficacy and safety of apixaban compared with warfarin according to age for stroke prevention in atrial fibrillation: observations from the ARISTOTLE trial. Eur Heart J. 2014;35(28):1864-1872, by permission of Oxford University Press.
Fig. 3 -
Fig. 3 -
Primary efficacy outcome of stroke or systemic embolism, major bleeding and intracranial hemorrhage in phase 3 randomized controlled trials comparing a NOAC with vitamin K antagonists in patients with atrial fibrillation according to age. BID = twice daily; HR = hazard ratio; NOAC = novel direct oral anticoagulant; QD = once daily. Modified from (27): Best Pract Res Clin Haematol, Vol. 26, No. 2, Barco S, Cheung YW, Eikelboom JW, Coppens M. New oral anticoagulants in elderly patients, pp. 215-224, Copyright (2013), with permission from Elsevier.
See this image and copyright information in PMC

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