Cardiac Rhythm Disorders in Older Adults

Contents

Preface xiii

Michael W. Rich and Win-Kuang Shen

Epidemiology of Arrhythmias and Conduction Disorders in OlderAdults 539

Grant V. Chow, Joseph E. Marine, and Jerome L. Fleg

Normal aging is associatedwith amultitude of changes in the cardiovascularsystem, including decreased compliance of blood vessels, mild concentricleft ventricular hypertrophy, an increased contribution of atrial contractionto left ventricular filling, and a higher incidence ofmany cardiac arrhythmias,both bradyarrhythmias and tachyarrhythmias. Conduction disorders alsobecomemore commonwith age, andmayeither be asymptomatic, or causehemodynamic changes requiring treatment. The epidemiology of commonarrhythmias and conduction disorders in the elderly is reviewed.

Mechanisms of Arrhythmias and Conduction Disorders in OlderAdults 555

Mahek Mirza, Anton Strunets, Win-Kuang Shen, and Arshad Jahangir

Aging is associated with an increased prevalence of cardiac arrhythmias,which contribute to higher morbidity and mortality in the elderly. The fre-quency of cardiac arrhythmias, particularly atrial fibrillation and ventriculartachyarrhythmia, is projected to increase as the population ages, greatlyimpacting health care resource utilization. Several clinical factors associ-ated with the risk of arrhythmias have been identified in the population,yet the molecular bases for the increased predisposition to arrhythmogen-esis in the elderly are not fully understood. This review highlights the epide-miology of cardiac dysrhythmias, changes in cardiac structure and functionassociated with aging, and the basis for arrhythmogenesis in the elderly.

Pharmacology of Antiarrhythmic Drugs in Elderly Patients 575

William H. Frishman and Wilbert S. Aronow

Bradyarrhythmias and tachyarrhythmias are common in elderly patients asa result of aging and acquired cardiac disease. Antiarrhythmic drugs are ef-fective in elderly patients for the management of supraventricular and ven-tricular arrhythmias; however, dosing of drugsmust be performed with carebecause of age-related changes in drug pharmacokinetics, the presence ofconcomitant disease, and frequent drug-drug interactions. Despite thelarge number of antiarrhythmic drugs having different electrophysiologicactions, as described in this article, only the b-blockers have been shownto be effective in reducing mortality and to lack proarrhythmic actions.

Atrial Fibrillation: Stroke Prevention in OlderAdults 617

Gene R. Quinn and Margaret C. Fang

Atrial fibrillation (AF) is an increasingly prevalent disease in the elderly.Patients with AF are at increased risk of ischemic stroke, resulting in

Contentsviii

significant morbidity and mortality. Warfarin is highly effective at reducingstroke risk, with a net clinical benefit favoring treatment in older individuals.The advent of newer oral anticoagulants provides promising alternatives towarfarin. Appropriate risk stratification for stroke should be performed forall patients with AF to guide antithrombotic therapy. For patients at lowerstroke risk, bleeding risk stratification tools can also be used when thebenefit of anticoagulant therapy is unclear.

Atrial Fibrillation and Atrial Flutter: Medical Management 635

Jane Chen

Atrial fibrillation (AF) and atrial flutter (AFL) are common cardiac arrhyth-mias in older adults. Medical management focuses on rate and rhythmcontrol of AF and AFL to promote symptomatic relief and avoid tachycar-dia-mediated cardiomyopathy. Pharmacologic treatment of AF and AFL isespecially challenging in the elderly because of the presence of comorbid-ities that may affect drug kinetics, and polypharmacy, which may lead todrug interactions. The potential for complications from medications andprocedures required to achieve and maintain sinus rhythm must be care-fully balanced against the benefits of therapy. This article reviews medicalmanagement of AF and AFL specifically relating to rate and rhythm control.The controversy of rate versus rhythm control is also discussed.

Atrial Fibrillation and Atrial Flutter: Nonpharmacologic Therapy 649

David L. Johnson, John D. Day, John R. Doty, and T. Jared Bunch

As elderly patients present significant challenges for long-term pharmaco-logic management, nonpharmacologic treatment of atrial fibrillation (AF)will continue to be a vital option in improving the quality of life and functionof these patients. This review discusses nonpharmacologic approachesfor AF in the elderly. Observational studies of catheter ablation suggestsimilar long-term efficacy and safety rates in elderly and younger groups.Minimally invasive surgical approaches have distinct advantages in certainpopulations. Further research, adequately powered to assess age-relateddifferences, is needed to confirm the findings of observational studies ofelderly patients who have undergone nonpharmacologic approaches torhythm control.

VentricularArrhythmias in the Elderly: Evaluation and Medical Management 665

Miguel A. Leal, Michael E. Field, and Richard L. Page

Ventricular arrhythmias constitute themain cause of sudden cardiac death.In the elderly, their presentation may be manifested by intermittent confu-sion or unexplained falls. In some cases, they may also be asymptomatic.The primary management goals are to identify and treat the underlyingcause and prevent recurrence. With the exception of beta-blockers, noneof the other antiarrhythmic drugs available reduce mortality associatedwith ventricular arrhythmias. In the elderly, these drugs are associatedwith a higher risk of adverse events. In this article, the authors review thedata available regarding evaluation andmanagement of ventricular arrhyth-mias in the elderly.

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VentricularArrhythmias: Device Therapy and Ablation 679

Jonathan P. Man and Andrew E. Epstein

There are few randomized, well-controlled studies to guide decision mak-ing with respect to the treatment of ventricular arrhythmias in the elderlytreated with either device implantation or catheter ablation. Althoughsome data are conflicting, the elderly appear to have a greater degree ofrisk related to treatment compared with younger ones; however, this in-creased risk is in part a consequence of age itself and comorbid condi-tions. Conversely, in terms of benefit, although the data may again bemixed, there is ample information indicating that age should not contrain-dicate aggressive treatment when accepted indications for interventionexist.

Quality of Life and End-Of-Life Issues for Older Patients with Implanted CardiacRhythm Devices 693

Rachel Lampert

This article provides an overview of quality of life (QOL) and end-of-life is-sues that pertain to older patients with implanted cardiac rhythm devices.Most patients with implantable cardioverter-defibrillators (ICDs) enjoy sim-ilar QOL to that of other patients with cardiac diseases, especially in theabsence of ICD shocks. Conventional pacemakers, as well as devices in-corporating cardiac resynchronization, can improve QOL in appropriatelyselected patients regardless of age. In patients approaching the end of life,all devices, but especially ICDs, can adversely impact QOL in patients andfamilies. All patients should have the opportunity to discuss the option ofdevice deactivation.

Bradyarrhythmias in the Elderly 703

Preetham Kumar, Fred M. Kusumoto, and Nora Goldschlager

Over the next decade, there will be a dramatic increase in the number ofelderly people in the United States and in most parts of the world. Withthis increase, there will be an accompanying increase in patients with sinusnode dysfunction and atrioventricular block; therefore, it will be essentialfor health care personnel to have a basic knowledge of bradyarrhythmiasand the considerations required for managing these rhythms in elderlypatients. In particular, comprehensive assessment before decisions onmedical and device-based management is critical and must take intoaccount social issues and the presence of comorbid conditions.

Syncope: Evaluation and Management in the Geriatric Patient 717

Blair P. Grubb and Beverly Karabin

Syncope is a common clinical problem accounting for 3% of all emergencyroom visits and 1% to 6% of all hospital admissions. Both a sign anda symptom, syncope can be caused by a wide variety of conditions. Syn-cope in the geriatric patient can be a particularly challenging problembecause of the coexistence of multiple possible causative pathologic con-ditions in the same individual. This article reviews the causes, evaluation,and management of syncope in the elderly.

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Management of Arrhythmias in the Perioperative Setting 729

Rowlens M. Melduni, Yuki Koshino, and Win-Kuang Shen

Perioperative arrhythmias are a common complication of surgery, with in-cidence ranging from 4% to 20% for noncardiothoracic procedures,depending on the type of surgery performed. The immediate postoperativeperiod is a dynamic time and is associated with many conditions condu-cive to the development of postoperative arrhythmias. The presence ofpostoperative atrial fibrillation is associated with increased morbidity,ICU stay, length of hospitalization, and hospital costs. The associated bur-dens are expected to rise in the future, given that the population undergo-ing cardiac surgery is getting older and sicker. Thousands of patientsundergo major surgery each year and a major complication of these pro-cedures is the occurrence of perioperative arrhythmia. It is imperative forclinicians to be up-to-date on current management of these arrhythmias.

Index 745