Arrhythmias in the elderlyArrhythmias in the elderly

Something old, something new?Something old, something new?

10th AGM, BGS Cardiovascular Section, London - July ‘10

John P. BourkeConsultant & Senior Lecturer in Cardiology

Freeman Hospital

Arrhythmias in the elderlyArrhythmias in the elderly

◊ Changing aetiology of arrhythmias with age

◊ Congenital arrhythmias still present ....

◊ Update on atrial fibrillation management

◊ Ventricular tachy-arrhythmias in the elderly

◊ Device therapy dilemmas in the elderly

Aetiology of Arrhythmias by AgeAetiology of Arrhythmias by Age

CongenitalCongenital oror AcquiredAcquired

Younger

Middle-aged

ElderlyBrady- or Tachycardias

Congenital Arrhythmias in the Elderly ...?!Congenital Arrhythmias in the Elderly ...?!

• Those that have been putting up with SVTs for years• Increasing SVT frequency due to increased ectopy despite drugs• Emergence of pre-excitation due to AV-nodal disease or medications

• Catheter ablation equally applicable with 95% success rates• SVT with BBB commoner & may complicate diagnosis• AV-nodal modification (AVJRT) carries higher risk of AV-block• WPW as bystander to acquired atrial tachy-arrhythmias

– SVT stops with CSM / Adenosine is the key to Dx –

- SVT returns > 2 yrs after successful ablation = different arrhythmia -

Mrs DMcD – Aged 88 yrs

• Long history of narrow QRS tachycardias

• Infrequent episodes since started amiodarone early 1990s– Became hypothyroid 1998– Amiodarone discontinued & EP / Ablation recommended

• EP-study 1998 (shortly after amiodarone withdrawal) – aged 76 yrs– all conduction very sluggish– no inducible arrhythmias & arrhythmia substrate indeterminate (? atrial tachycardia)

• EP-repeat study 2010– Concealed accessory pathway confirmed with AV-reentrant SVT– Ablation of left free wall pathway with single lesion

1. Good example of amiodarone’s typical long-term toxicity profile

2. Complicating effect of amiodarone on diagnosis & ablation

3. SVT-ablation’s success is not age dependent

Acquired ArrhythmiasAcquired Arrhythmias

1100 Electrical Electrical

- Age-related AF / A-flutter- Tachy-brady syndrome (Sinus node Ds)

2200 to Structural Disease to Structural Disease

- Hypertensive heart Ds

- Post-infarction / Cardiomyopathy- Valve disease (eg: MR or AR)

Atrial Fibrillation & Ventricular TachycardiaAtrial Fibrillation & Ventricular Tachycardia

Atrial Fibrillation Atrial Fibrillation a degenerative conditon of ‘old age’ (?)a degenerative conditon of ‘old age’ (?)

AF=atrial fibrillation; A&E=accident and emergency; MAU=medical assessment unit; CoE=care of the elderly; GenMed=general medical

Complex patient-pathways in Atrial FibrillationComplex patient-pathways in Atrial Fibrillation

Other Spec.CardiologyA&E/MAUPrimary Care

Other Spec.Cardiology CoE/GenMedPrimary Care

44% diagnosed in primary care

28% 9% 18%

20% remain in primary care

68% referred tocardiology

90% referred to primary care formanagement

40% 25% 34%

26%

65%

About 50% patients with AF are diagnosed in 10 care & 20% remain there for management

Diagnosis

Sinus Rhythm

Persistent Persistent AF AF

Paroxysmal Paroxysmal AFAF

Permanent Permanent AF AF

Cardioversion

““Atrial fibrillation begets atrial fibrillation”Atrial fibrillation begets atrial fibrillation”

Eroding anti-AF threshold

Secondary electrical changesMore frequent / longer episodes

Secondary electrical changesSecondary structural changesNo longer able to restore / maintain SR

Evolving Triggers & substrates

When is it pointless to call the fire brigade?

Rhythm control Rhythm control

management management

cannot be an cannot be an

afterthought …!afterthought …!

Challenge of deploying newer therapies optimallyChallenge of deploying newer therapies optimallyEquality of access to treatment options..?Equality of access to treatment options..?

• Anti-arrhythmic management– Dronedarone / Vernakalant– Pacing & AV-nodal ablation– Catheter ablation

DDDRP

• Stroke Prevention - Warfarin vs Dabigatran - Left atrial occlusion devices

• Newer options in valve disease - Mitral valve clips for MR - TAVI for AS - Timing of surgical MVR

AFFIRM AFFIRM STUDYSTUDY

InclusionInclusion

Age > 65

or 1 major risk factor for death or stroke

AF – The rhythm versus rate control debateAF – The rhythm versus rate control debate

Does this mean sinus rhythm & AF equivalent?

NO !NO !62.6

34.638.7

10

38

9

AFFIRM RACE STAF

% pts in SR at study end

rhythm control

rate control• Recruited only mildly symptomatic pts, who could be randomized to either strategy

•Success of rhythm control poor with AA Rx

• Survival benefits offset by effects of AADs

• Spontaneous reversion to SR high

◊ Presence of AF was associated with worse NYHA-FC (p < 0.0001)

◊ Improved in 6-minute walk test in rhythm control group (p = 0.049)

Effect of rate & rhythm control on left ventricular function & cardiac

dimensions in patients with persistent atrial fibrillation: RACE Study RACE Study

Echo study with 1-2 year follow-up (N = 335)In rhythm control group LV-function compared between SR & AF pts at study end

Hagens et al. Heart Rhythm 2005, 2:19-24

◊ Routine rate control prevents deterioration of LV-function.

◊ Maintenance of sinus rhythm improves LV-function & reduces atrial sizes

Circulation 2004, 109:1509-15

◊ Variables associated with increased risk of death- Increasing age- Coronary artery disease- Congestive cardiac failure; Left ventricular dysfunction- Diabetes mellitus or smoking- Stroke or TIA- Mitral regurgitation

◊ Variables associated with reduced risk of death- Maintenance or sinus rhythm- Warfarin therapy

◊ Anti-arrhythmic drugs ≠ improved survival- any benefits are offset by adverse effects

AHA Guidelines 2006AHA Guidelines 2006Dronedarone & atrial-selective anti-arrhythmic agents (?)

Dronedarone Vernakalant (acute cardioversion)

Atrially-selective anti-arrhythmic agent(s)Atrially-selective anti-arrhythmic agent(s)

VernakalantVernakalant

• Atrially-selective potassium channel blocker with short half life

• Reduced risk of pro-arrhythmia & negative inotropic effects

• Currently an iv drug for acute cardioversion of recent onset AF

• Oral version likely to follow for maintenance of SR

May reduce the threshold for attempted cardioversion in borderline cases

(no GA or sedation required; ‘less inconvenient’)

Non-pharmacological therapies Non-pharmacological therapies

for AF in the elderly .....?for AF in the elderly .....?

AHA Guidelines 2006AHA Guidelines 2006

Pappone APAF JACC Oct 06

Outcome of AF ablation - randomized comparison of Outcome of AF ablation - randomized comparison of ablation vs drugsablation vs drugs

NavX-guided point-by-point isolation of pulmonary veins &

‘roof line’

LA & Pulmonary Veins

Ablation lesion

Radiofrequency catheter ablation of AF in older patients Radiofrequency catheter ablation of AF in older patients Outcomes & ComplicationsOutcomes & Complications

N = 240 < 65 years 65-75 years > 75 years p

N 91 88 61 ---

Persistent AF 24% 34% 66%* < 0.01

Major complications 1% 1% 0% NS

Minor complications 4% 5% 5% NS

SR without AARx 94%* 84% 61% < 0.01

Hospital attendancesPre- vs Post-ablation 22 / 3 26 / 4 20 / 2 < 0.01

Patients > 75 years: AF < 1 hour Patients > 75 years: AF < 1 hour ++ AARx = AARx = 82%82%

Selection criteria for catheter ablation of AFSelection criteria for catheter ablation of AF

• Technically it can be preformed in almost anyone .... but it’s primarily Technically it can be preformed in almost anyone .... but it’s primarily indicated for symptom control not for prognosisindicated for symptom control not for prognosis!!

• Best results Best results - No structural heart disease & paroxysmal AFSerious complications = 1-2% per procedureSuccess = 85% with 1-2 procedures

•• Less predictable resultsLess predictable results – persistent AF & dilated LA / LVHSuccess = 70% with 1-2 procedures

•• Research proceduresResearch procedures – paroxysmal or persistent AF in CCF / HCM or chronic persistent AF (> 12 mths)

• Sustained palpitations for several hours

Anxious but stable; ECG confirms AF; ventricular rate = 110 / min

She is on no cardio-active medications

• Increasingly frequent similar episodes x 14 months, lasting < 4 hours

Episodes tend to start when she is at rest or even asleep.

• Recently, feels faint as palpitations terminate with two falls resulting

82 yrs old female presents to A&E82 yrs old female presents to A&E

2.4 sec

5.4 sec pause post-AF

Low Heart Rate Variability = SSS & AF

AF in tachy-brady syndrome likely AF in tachy-brady syndrome likely to be abolished by atrial pacingto be abolished by atrial pacing

DDDRP

Correct sinus node Ds & restore chronotropic competence

+

To allow anti-arrhythmic drugs to control tachycardia

Atria

Ventricles

Arrhythmias in the elderlyArrhythmias in the elderly

◊ Changing aetiology of arrhythmias with age

◊ Congenital arrhythmias still present ....

◊ Update on atrial fibrillation management

◊ Ventricular tachy-arrhythmias in the elderly

◊ Device therapy dilemmas in the elderly

Ventricular Tachy-arrhythmiasVentricular Tachy-arrhythmias

in the elderlyin the elderly

A Matter of A Matter of Life or DeathLife or Death

The same arrhythmia – very different management ... !?The same arrhythmia – very different management ... !?

1. Why did it happen ?

2. Will it recur ?

3. Does it require post-acute management ?

4. Does it require specific anti-arrhythmic management ?

Acute ischaemia / MIDrug induced

Biochemical upset

... ‘One-off’ event?

Remote MIPoor LV function

Highly likely to recur!

Commonest cause of VT is old myocardial infarctionCommonest cause of VT is old myocardial infarction

■ 72 yr old male

■ PHx: inferior MI (1989)

■ CABG x 4 (1990)

■ LVEF = 32%

■ Rx: bisoprolol, ramipril, simvastatin, aspirin

Commonest cause of VT is old myocardial infarctionCommonest cause of VT is old myocardial infarction

Progressive LV-dysfunction Renewed coronary ischaemia

As well as the arrhythmia recurrences ...As well as the arrhythmia recurrences ...

AVID Trial AVID Trial (2ndry prevention)

‘ ... Among survivors of VF or

sustained VT, causing severe

symptoms, the ICD is superior to

anti-arrhythmic drugs for increasing

overall survival ...’

N Engl J Med 1997, 337:1576-83.

If ‘high risk’ of arrhythmia recurrence ...

P < 0.02

AVID Study

Mrs WJ - 78 yrs

■ ■ Jan ‘10:Jan ‘10: OPD referral - ‘Palpitations’ / No LOC or compromise

- Uncomplicated anterior MI (2008)

- Examination: No abnormalities

- Hx suggestive of isolated ectopic beats

■ ■ OtherOther:: ACEi, BB, statin & aspirin therapy

Ex-smoker (10 / day)

Normotensive

No DM

Mrs WJ - 78 yrs

Mrs WJ - 78 yrs

■ Investigations

Holter ECG Non-sustained VT (8 bts / 200 bpm) – symptoms (+)

Echo Large anterior LV-akinetic segment (LVEF 34%)

Cor angios No obstructive coronary lesions

Ms WJ - EP-Testing: Is she capable of sustained VT?Is she capable of sustained VT?

RV Drive

Sustained VT

2 extras

Mrs WJ - 78 yr - VT induce in EP-Lab

VT CL = 230ms (260 bpm)

MADIT I Trial MADIT I Trial EP-testing(+)

‘ ... In patients with prior MI, who are at

high risk of VT / VF, prophylactic therapy

with an ICD leads to improved survival

compared to conventional medical

therapy’ N Engl J Med 1996, 335:1933-40

p = 0.009

MADIT I TrialMADIT I TrialPrimary Prevention

LVEF < 35% & NSVT & inducible VT

Mr RL - 80 yrs

■ Aug ‘09: Admitted to DGH after collapse & spontaneous recoveryAlso several previous ‘dizzy spells’

■ PHx: Ischaemic heart DsPrevious anterior MILBBB on ECG (QRS = 120 ms)

LVEF < 30%

■ Rx: lisinopril, metoprolol, furosemide, L-thyroxine, allopurinol

MADIT II Trial MADIT II Trial (No EP testing)

‘ ... In patients with prior MI &

advanced LV-dysfunction,

prophylactic ICD implantation

improves survival and should be

considered as a recommended

therapy‘N Engl J Med 2002, 346:877-83

P = 0.007

MADIT II TrialMADIT II Trial

Primary PreventionLVEF < 35% & NSVT alone

Total Mortality Benefits - NNTT

♥♥ Combining all trials Combining all trials (1(100 & 2 & 200 prevention; Post MI & DCM) prevention; Post MI & DCM)

NNTT (1 death in 2 years) = 13

But depends on baseline riskBut depends on baseline risk

♥♥ If primary prevention with post-infarction & LVEF < 30%

NNTT (1 death over 2 yrs) = 18

♥♥ If same background & inducible VT

NNTT (1 death over 2 yrs) = 4

Most of the benefit .... Most of the benefit ....

Patients with CADs, LV-dysfunction & inducible VT at EP study

Less benefit ... Less benefit ...

Moderate risk group or CABG or DCM

Pacing to improve coordination of cardiac contraction(atrio-ventricular; inter- & intra-ventricular resynchronisation)

Pacing to improve LV-functionPacing to improve LV-function

LV

RA

RVA

Electrical

resynchronization

Cardiac resynchronisation therapy Cardiac resynchronisation therapy ++ ICD component ICD component

CRT & CRT & CRTDCRTD

11

22

33

MADIT-CRT TrialMADIT-CRT TrialTo assess whether CRT-D reduces mortality &

heart failure events in patients with:NYHA class I-IIQRS > 130msLVEF < 30%

■ 34% reduced all-cause mortality or 1st heart failure event with CRT-D (p < 0.001)

■ 41% reduction in HF events (p < 0.001)

■ Benefits IHD = DCM

p < 0.001

Arrhythmias in the elderlyArrhythmias in the elderly

◊ Changing aetiology of arrhythmias with age

◊ Congenital arrhythmias still present ....

◊ Update on atrial fibrillation management

◊ Ventricular tachy-arrhythmias in the elderly

◊ Device therapy dilemmas in the elderly

A simple scenario ..?A simple scenario ..?

◊ 79 yr old lady referred with symptomatic CHB of recent onset

◊ Asymptomatic coronary Ds (ie: no active ischaemia) & previous LBBB

◊ Old inferior MI, LVEF 25% & NYHA II dyspnoea

◊ Recent drug therapy: ACEi, Beta-blocker, Statin, Aspirin & Furosemide

Requires permanent pacing

Made unnecessarily complex ....???Made unnecessarily complex ....???

What is her most appropriate therapy?

Standard Pacemaker

(2-leads)

Resynchronisation Pacemaker

(3-leads)Combined Resynchronisation

Pacing & Defibrillator

Arrhythmias in the elderlyArrhythmias in the elderly

◊ Changing aetiology of arrhythmias with age

◊ Congenital arrhythmias still present ....

◊ Update on atrial fibrillation management

◊ Device therapy dilemmas in the elderly