EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA)

Abstract

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

Keywords: Ablation; Antiarrhythmic drugs; Anticoagulants; Arrhythmias; Atrial fibrillation; Cachexia; Cardiac resynchronization therapy; Cardiac resynchronization therapy-defibrillator; Cognitive impairment; Consensus document; Elderly; European Heart Rhythm Association; Frailty; Frailty assessment; Frailty domains; Frailty syndrome; Heart failure; Implantable cardioverter-defibrillator; Pacemaker; Position paper; Pre-frailty state; Stroke; Ventricular tachycardia.

Figure 1

Flow diagram for the identification of unexplained falls. Reproduced from Brignole M, et al. 2018 ESC Guidelines for the diagnosis and management of syncope. European Heart Journal, 2018;39(21):1883–1948, by permission of Oxford University Press and the European Society of Cardiology (ESC).

Figure 2

The ABC-integrated AF management pathway. Adapted from Lip GYH. ABC, Atrial fibrillation Better Care; AF, atrial fibrillation; NOAC, non-vitamin K antagonist oral anticoagulant; OAC, oral anticoagulant; TTR, time in therapeutic range; VKA, vitamin K antagonist.