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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EA common issue in the management of elderly patients with atrial fibrillation (AF) is weighing the relative risks of ischemic stroke and bleeding. The article addresses subclinical atrial fibrillation, ablation in the elderly, and stroke prevention with new oral anticoagulants, as well as left atrial appendage closure.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPrevention \u0026amp; Screening\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPrevention \u0026amp; Screening\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPrevention \u0026amp; Screening\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology \u0026amp; Cardiovascular Medicine\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EA common issue in the management of elderly patients with atrial fibrillation (AF) is weighing the relative risks of ischemic stroke and bleeding. The presentations in this session addressed subclinical atrial fibrillation (SCAF), ablation in the elderly, and stroke prevention with new oral anticoagulants (NOACs) as well as left atrial appendage (LAA) closure.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESUBCLINICAL ATRIAL FIBRILLATION DIAGNOSIS AND TREATMENT IMPORTANT FOR STROKE PREVENTION\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EMuch has been learned about atrial tachyarrhythmia (AT) over the last 15 years in studies using pacemakers, which accurately record atrial rhythm changes for prolonged periods. According to presenter Jeff Healey, MD, MSC, McMaster University, Hamilton, Ontario, Canada, pacemakers are the gold standard for detecting atrial high-rate episodes (AHRE).\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EIn a study of 110 patients, recurrent AT was detected in 46% by electrocardiogram (ECG) and in 88% by pacemaker at 19 months follow-up [Israel CW et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2004]. AT duration was \u0026gt;48 hours in 50 patients, 19 (38%) of whom were asymptomatic and in sinus rhythm at follow-up.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003ESeveral studies have demonstrated increased stroke rates among patients with SCAF (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E). Patients with a high SCAF burden (\u22655.5 hours) were more likely to have a stroke than those with a lower burden [Glotzer TV et al. \u003Cem\u003ECirc Arrhythm Electrophysiol\u003C\/em\u003E 2009]. The ASSERT trial found that SCAF was associated with a 2.5-fold increased stroke risk but the absolute stroke risk was modest at 1.69%\/year [Healey JS et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2012]. Only 8% of ASSERT stroke patients had SCAF within 30 days before the event [Brambatti M et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2014].\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15862\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15862\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15862\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EStudies of Relationship Between Device-Detected SCAF and Ischemic Stroke\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EProf. Healey concluded that SCAF is common and is associated with an increased risk of stroke. However, the absolute risk of stroke and the relationship of SCAF with stroke are different than for clinical AF. The role of anticoagulation in SCAF is not known.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EFAVORABLE RISK-BENEFIT PROFILE OF NEW ORAL ANTICOAGULANTS IN THE ELDERLY\u003C\/h2\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EMichael W. Rich, MD, Washington University School of Medicine, St. Louis, Missouri, USA, presented data on the use of novel oral anticoagulants (NOACs) in elderly patients with AF.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003ECompared with warfarin, dabigatran 110 mg [RE-LY; Connolly SJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009] and rivaroxaban [ROCKET-AF; Patel MR et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011] were noninferior for preventing stroke, while dabigatran 150 mg and apixaban [ARISTOTLE; Granger CB et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011] were superior. Major bleeding rates with dabigatran 150 mg and rivaroxaban were similar to warfarin but were significantly lower than warfarin with dabigatran 110 mg and apixaban. Intracranial hemorrhage was significantly lower with either of the dabigatran doses, rivaroxaban and apixaban when compared to vitamin K antagonist therapy. Subgroup analyses showed no increase in bleeding with rivaroxaban [Goodman SG et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2014] or apixaban [Halvorsen S et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2014] among elderly patients. Bleeding complications increased with dabigatran in patients with reduced renal function [Hijazi Z et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2014].\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EIn the WOEST trial [Dewilde WJM et al. \u003Cem\u003ELancet\u003C\/em\u003E 2013], patients on oral anticoagulation undergoing PCI were randomized to clopidogrel alone or clopidogrel versus acetylsalicylic acid. At 1 year, any bleeding occurred in 19.4% of patients on double therapy versus 44.4% on triple therapy (HR, 0.36; 95% CI, 0.26 to 0.50; p\u0026lt;0.0001). Death or cardiac event rates were lower with double therapy (HR, 0.60; 95% CI, 0.38 to 0.94; p=0.025).\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003ENOACs have a favorable risk-benefit profile versus warfarin in elderly patients with AF. Existing data suggests that double therapy with clopidogrel and an anticoagulant may be safer than triple therapy with similar efficacy. The decision to use anticoagulants in older patients must be individualized.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESTROKE PREVENTION IN ELDERLY PATIENTS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-13\u0022\u003ERandall I. Lee, MD, University of California, San Francisco, San Francisco, California, USA, discussed the evidence for using anticoagulation versus an implanted device in elderly patients with AF. Stroke resulting from thrombus formation in the left atrial apendage (LAA) is the most threatening consequence of AF. The primary preventive therapy is anticoagulation. The most commonly used anticoagulant is warfarin, which is not optimal due to its narrow therapeutic window, low compliance, contraindications, and increased risk in the elderly.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EThe NOACs are noninferior or superior to warfarin for preventing stroke and generally are associated with comparable or lower rates of bleeding.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003ELAA closure is another option for stroke prevention in patients with AF. The PROTECT-AF trial [Holmes DR et al. \u003Cem\u003ELancet\u003C\/em\u003E 2009] demonstrated noninferiority of the implanted Watchman device compared with warfarin for stroke prevention but periprocedural complications were more frequent than warfarin adverse events.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EThe LARIAT device is a snare with a pretied suture that is guided epicardially over the LAA. The PLACE II trial [Bartus K et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2013] demonstrated LAA closure with the LARIAT device and no device-related complications. Adverse events included access-related complications (3%), unexplained sudden deaths (2%) and pericardial effusion (1%) but no bleeding.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EDr. Lee concluded that the initial embolic risks and adverse events associated with Watchman device implantation may not outweigh the long-term bleeding risks of NOACs. Observational studies of the Lariat device are promising but randomized trials have not been conducted.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EABLATION FOR ATRIAL FIBRILLATION IN THE ELDERLY\u003C\/h2\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EThomas M. Munger, MD, Mayo Clinic, Rochester, Minnesota, USA, discussed AF ablation versus atrioventricular node ablation (AVNA) with permanent pacemaker implantation in patients aged \u0026gt;75 years old. The 2012 Heart Rhythm Society\/European Heart Rhythm Association\/European Cardiac Arrhythmia Society Consensus Statement on catheter and surgical ablation of atrial fibrillation [Calkins H et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2012] summarized the results of eight randomized studies on AF catheter ablation. At 1 year, ablation was superior to antiarrhythmic drugs or rate control (66% to 89% vs 9% to 58% freedom from AF).\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EA study of long-term outcomes of AF catheter ablation reported a 47% recurrence rate at 3 years [Wokhlu A et al. \u003Cem\u003EJ Cardiovasc Electrophysiol\u003C\/em\u003E 2010]. Univariate predictors for ablation failure included hypertension, diabetes, persistent pattern, family history, and large atria. In the MAZE III study [Stulak JM et al. \u003Cem\u003EAnn Thorac Surg\u003C\/em\u003E 2007] of surgical ablation for AF, 64% of patients with paroxysmal AF and 62% of those with persistent AF were free from AF at 10 years post ablation. A wide variety of complications are associated with AF catheter ablation, including silent microemboli (7% to 38%) [Calkins H et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EResults of AVNA trials in patients with AF are shown in \u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15864\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15864\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15864\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-21\u0022 class=\u0022first-child\u0022\u003EAtrioventricular Nodal Ablation Trials\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-23\u0022\u003EAccording to Dr. Munger, virtually no studies have compared AF ablation and AVNA ablation. There is a need for head-to-head trials and ablation registry studies, especially in the elderly. Future studies should include single procedure results, primary outcomes of freedom from AF without antiarrhythmic drugs, AF burden assessment at various points, and cost analyses.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/4\/31.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzpc6p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzpc6p\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}