© Borgis - Postępy Nauk Medycznych 7/2015, s. 458-462
*Agata Bogołowska-Stieblich, Agata Kusz-Rynkun, Marek Tałałaj
Leczenie migotania przedsionków u pacjentów w podeszłym wieku
The strategies of treatment of atrial fibrillation in the elderly
Department of Family and Internal Medicine and Metabolic Bone Diseases, Orlowski Hospital, Medical Centre of Postgraduate Education, Warszawa
Head of Departament: Marek Tałałaj, MD, PhD, Associate Professor
Streszczenie
Migotanie przedsionków jest najczęściej występującą arytmią u osób w podeszłym wieku. Jego konsekwencją jest zwiększone ryzyko udaru mózgu, zastoinowej niewydolności serca i zwiększona śmiertelność. Osoby w podeszłym wieku są bardziej narażone na występowanie powikłań zakrzepowych, ale również na krwawienia związane z przyjmowaniem doustnych antykoagulantów. CHADS2 jest najprostszą skalą oceniającą ryzyko udaru mózgu, a HAS-BLED skalą oceniającą ryzyko krwawienia podczas leczenia doustnymi antykoagulantami. Leczenie migotania przedsionków koncentruje się na kontroli częstotliwości rytmu komór bądź utrzymywaniu rytmu zatokowego oraz na zapobieganiu udarowi mózgu za pomocą leków przeciwkrzepliwych. W przypadku zalecania terapii przeciwkrzepliwej należy rozważyć włączenie nowych doustnych antykoagulantów zamiast warfaryny, biorąc pod uwagę korzyści płynące z ich stosowania. Leki antyarytmiczne u osób starszych powinny być zalecane ze szczególną ostrożnością z uwagi na ich zmieniony metabolizm, zwiększone ryzyko interakcji lekowych i bradykardii. Leczeniem z wyboru starszych pacjentów z migotaniem przedsionków, zwłaszcza skąpoobjawowych, jest kontrola częstotliwości rytmu komór, a nie utrzymywanie rytmu zatokowego.
Summary
Atrial fibrillation (AF) is the most common arrhythmia in elderly people. AF is associated with high risk of stroke, congestive heart failure and with increased mortality. Elderly patients have the highest incidence of thrombotic complications as well as the highest risk of anticoagulant-associated bleeding. CHADS2 score is the simplest scheme to assess the risk of stroke, and HAS-BLED score is the scale to define the risk of bleeding during treatment with oral anticoagulants. The management of AF focuses on rate or rhythm control and the prevention of stroke with antithrombotic drugs. In case the antithrombotic therapy is recommended, new oral anticoagulants should be considered rather than warfarin concerning their greater clinical benefit. Antiarrhythmic drugs should be used carefully in elderly patients because of the frequency of metabolic abnormalities and higher risk of drug interactions and bradycardia. A rate-control rather than a rhythm-control strategy is the treatment of choice for AF in almost all elderly patients, especially if they are paucisymptomatic.
INTRODUCTION
Atrial fibrillation (AF) is the most common arrhythmia in older adults with a prevalence increasing from 0.1% among persons younger than 55 years to 9% in people aged 80 years or more. AF can cause various signs and symptoms including palpitations, dizziness, dyspnea, syncope, unstable hemodynamics, tachycardia-induced cardiomyopathy and stroke. Arrhythmia is associated with a five-fold increase in the risk of stroke, a three-fold rise in the incidence of congestive heart failure, and higher mortality (1). Diagnosing AF before the first complications occur is a well-recognized priority for the prevention of stroke. ESC Guidelines for the management of atrial fibrillation edited in 2012 recommend, in patients aged 65 years or over, an opportunistic screening for AF by pulse palpation, followed by an ECG in those with an irregular pulse to verify diagnosis, and to detect AF prior to the first incident of stroke (2). The management of AF focuses on rate or rhythm control and the prevention of stroke with antithrombotics.
STROKE RISK EVALUATION
Stroke related to atrial fibrillation is a growing global public health problem. Patients with AF have a variable risk of embolic stroke depending on both comorbid conditions and their age, as most AF patients are above 75 years. Older age is considered an independent risk factor for AF-associated stroke. CHADS2 score is the simplest scale to assess the risk of stroke (table 1 and 2).
Table 1. CHADS2 score.
| Risk factor | Score |
| Congestive heart failure | 1 |
| Hypertension | 1 |
| Age ≥ 75 years | 1 |
| Diabetes | 1 |
| Stroke or TIA | 2 |
| Maximum score | 6 |
Table 2. CHADS2 score and stroke rate.
| CHADS2 score | Adjusted stroke rate (%/year) |
| 0 | 1.9 |
| 1 | 2.8 |
| 2 | 4.0 |
| 3 | 5.9 |
| 4 | 8.5 |
| 5 | 12.5 |
| 6 | 18.2 |
The CHADS2 score is a simple, practical scale but it does not include many well recognized risk factors for stroke, e.g. vascular diseases. The CHA2DS2-VASc score was found to be better at identifying „truly low-risk” patients with AF while remained as good as CHADS2 in identifying patients who are at risk for developing thromboembolism and stroke (tab. 3). Its employment is particularly indicated in patients with CHADS2 score of 0-1 in order to better delineate the truly low-risk patients (2).
Table 3. CHA2DS2-VASc score.
| Risk factor | Score |
| Congestive heart failure/LV dysfunction | 1 |
| Hypertension | 1 |
| Age > 75 years | 2 |
| Diabetes mellitus | 1 |
| Stroke/TIA/thrombo-embolism | 2 |
| Vascular disease (i.e. prior myocardial infarction, peripheral artery disease, aortic plaque) | 1 |
| Age 65-74 years | 1 |
| Sex category (i.e. female sex) | 1 |
| Maximum score | 9 |
ANTITHROMBOTIC THERAPY
It was found that oral anticoagulant therapy with vitamin K antagonists (VKA) reduced the risk of ischemic stroke by 64% in patients with AF. Due to the significantly higher incidence of stroke in the elderly population, the absolute risk reduction in people aged > 65 years was much more pronounced than in younger individuals (3). Apart from considerably increased incidence of thrombotic complications elderly patients are characterized by the much higher risk of anticoagulant-associated bleeding (2). Because of this the final decision of starting treatment with oral anticoagulants should be preceded by careful assessment of the risk of bleeding. The ESC guidelines recommend to use the HAS-BLED score to determine risk (tab. 4). A score of ≥ 3 is considered to be indicative for high risk of bleeding and suggesting that some caution together with special medical attention and regular reviews of the patient are needed following the initiation of antithrombotic therapy.
Table 4. Clinical characteristics comprising the HAS-BLED bleeding risk score.
| Clinical characteristics | Points |
| Hypertension | 1 |
| Abnormal renal and liver function (1 point each) | 1 or 2 |
| Stroke | 1 |
| Bleeding | 1 |
| Labile INR | 1 |
| Elderly (age > 65 years) | 1 |
| Drugs or alcohol (1 point each) | 1 or 2 |
Considering their mechanisms of action, oral anticoagulants can be divided into several different groups. The oldest one comprise vitamin K antagonists (e.g. warfarin). The drugs inhibit the synthesis of vitamin K-depending clotting factors, including factors II, VII, IX, and X as well as the anticoagulant proteins C and S. Vitamin K antagonists are effective and inexpensive medicines, but they are characterized by many food and drug interactions and narrow therapeutic window. Their dosing has to be adjusted to ensure the therapeutic level of INR.
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