Managing atrial fibrillation in elderly people
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7191.1088 (Published 24 April 1999) Cite this as: BMJ 1999;318:1088
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Editor
We were interested to read English and Channer`s paper on managing
atrial fibrillation in the elderly 1. They suggest that using new low dose
starting regimens, such as that tested by Oates et al, 2 may facilitate
initiation of warfarin treatment in the community.
The Cumbria Practice Research Group is carrying out a study on atrial
fibrillation in the community, which includes initiating warfarin at 1mg
daily with weekly measurements of the International Normalized Ratio
(INR). The dose is increased in 1mg increments weekly until the target INR
is reached. The method proves to be easy to administer and avoids the
large swings in INR which sometimes occur when using the older method of
'loading doses' of warfarin. The study is still in progress and the full
results will be reported later. We did not have the benefit of Oates et
al's paper when planning the study, but their information is helpful
because their method may achieve the final dose of warfarin more quickly
than our method. This is all good news if it encourages more doctors to
initiate warfarin treatment in those at risk of stroke from atrial
fibrillation.
Eleri Roderick
General Practitioner
Jim Cox
General Practitioner
The Surgery
Caldbeck
Wigton
Cumbria CA7 8DS
1 English KM, Channer KS. Managing atrial fibrillation in elderly
people. BMJ 1999;318:1089-90.
2 Oates A, Jackson PR, Austin CA, Channer KS. A new regimen for starting
warfarin therapy in out-patients. Br J Clin Pharmacol 1998;46:157-61.
Competing interests: No competing interests
Editor
In noting the better efficacy of warfarin in preventing ischaemic
stroke compared to aspirin in those over 75 years in atrial fibrillation
English and Channer claim [1] and reference [2] that in those aged over
75 aspirin is often used despite its lack of efficacy in this age group.
This needs to be challenged. The indirect reference used does not
conclude as they claim, makes no reference to the subsequently completed
BAATAF and SPAF III trials as indicated, and recommends that in the very
elderly (over 75 years of age) patient with atrial fibrillation
anticoagulation should be used with caution[2]. The original reference
that did conclude as claimed is a SPAF (Stroke Prevention in Atrial
Fibrillation) subgroup analysis. [3] Subsequent work and other trials of
aspirin in atrial fibrillation suggest this conclusion might be a
statistical artifact. The second phase of the same study (SPAF II) showed
a non-significant risk reduction of 9% in total stroke rate in the over 75
age group to the advantage of warfarin compared to aspirin. Total
mortality, vascular mortality and strokes with residual defect were
actually less by up to 2% (non-significant) in the aspirin group over 75
years. [4] There have been no randomised controlled trials comparing
aspirin with warfarin controlled to an INR of less than 3.0 as is now
recommended in the otherwise fit over 75 age group. So we have no direct
evidence that aspirin is worse in overall outcome than warfarin. On meta-
analysis there is good evidence of aspirin's efficacy in the elderly [5],
although given the change in aetiology of disease including ischaemic
stroke with age, the very old might be suspected to benefit less from anti
-platelet agents. This meta-analysis included the three randomised
controlled trials of aspirin in atrial fibrillation but because of the
small numbers of very old enrolled in a randomised fashion we are probably
less clear about the overall benefits of aspirin as opposed to the
increasing risks of warfarin as the patient gathers more pathology.
Many patients over 75 years in atrial fibrillation could be better
off on aspirin than on warfarin. Practice in preventing common conditions
in the elderly has a long history of being unnecessarity nilistic and it
is particularily important not to confuse lack of overwhelming evidence
with lack of efficacy, when mounting a large enough clinical trial to
resolve a question will be difficult. The place of anti-platelet agents in
prevention in the very old needs better definition, but the very old in
atrial fibrillation who are not offered anticoagulation should not be
denied anti-platelet therapy on current evidence.
Michael L Jenkinson
Consultant Physician
Queen Elizabeth
The Queen Mother Hospital
Margate CT9 4AN
1 English KM, Channer KS. Managing atrial fibrillation in elderly
people. BMJ 1999 318:1088-1089
2 Albers GW. Atrial fibrillation and stroke. Three new studies, three
remaining questions. Arch Intern Med 1994;154:1443-57
3 Stoke Prevention in Atrial Fibrillation Investigators. A differential
effect of aspirin on prevention of stroke in atrial fibrillation. J Stroke
Cerebrovascular Dis. 1993:3;181-8
4 Stoke Prevention in Atrial Fibrillation Investigators. Warfarin verus
aspirin for prevention of thromboembolism in atrial fibrillation: Stroke
prevention in atrial fibrillation II study. Lancet 1994;343:687-691
5 Antiplatelet Trialists' Collaboration. Collaborative overview of
randomised trials of antiplatlet therapy-I:Prevention of death, myocardial
infarction, and stroke by prolonged antiplatelet therapy in various
categories of patients. BMJ 1994;308:81-106
Competing interests: No competing interests
Dear Sir
May I express a smidgen of surprise that you can print a review of
the management of atrial fibrillation in the elderly without reference to
digoxin. This was presumably a deliberate act by the authors, which cannot
be allowed to go unquestioned.
Sinus rhythm is desirable; knowledge of the onset of AF is often
absent- strangely it can be asymptomatic. Anticoagulation is accepted by
most physicians for those who cannot be maintained in sinus rhythm.
I believe that digoxin should continue to be the drug of choice for
those patients who remain in AF. At present amiodarone is being continued
in many patients who have reverted (as many do) to AF.
Yours sincerely
Richard Whitmore
Hatfield Lane
Norton, Worcester
WR5 2PY
Competing interests: No competing interests
Dear Editor
Dr English and Channer in their article [1] highlighted the
suboptimal treatment of atrial fibrillation in elderly patients but have
omitted a few important facts.
Elderly patients with atrial fibrillation are not a homogenus group with
difference between relatively young and very elderly patients i.e. those
over 80 years of age. Most evidence for cardioversion and anticoagulation
is based on well motivated and relatively younger patients while the bulk
of workload in most elderly care departments is in the older age group.
The evidence for suitability of treatment in the younger elderly can not
be extrapolated to very elderly patients where there is high comorbidity,
dementia, social isolation and increased side effects to most
pharmacological and non pharmacological interventions.
In principal the concept of electrical cardioversion for acute atrial
fibrillation is well accepted but there is little evidence for its use and
adverse effects in very elderly patients. The non-availability or access
to
equipment such as transthorasic and transoesophegial echocardiography,
adequately trained medical and nursing staff and monitoring facilities at
all hours is another reason for suboptimal treatment in relation to
electrical
and chemical cardioversion.
More research and resources are required to optimise treatment of
atrial fibrillation in hospitals and for monitoring anticoagulation
therapy in the community.
Yours sincerely
Dr S A Khan
Consultant Physician
Department Care of the Elderly
Lister Hospital
Corey's Mill Lane
Stevenage
Herts SG1 4AB
Reference
1 English KM, Channer SK. Mannaging atrial fibrillation in elderly
patients. BMJ;318:1088-1089.
Competing interests: No competing interests
Dear Editor,
There are factual errors which require correction in this week’s
editorial by English and Channer on managing atrial fibrillation in
elderly patients. The authors state that the BAATAF and SPAF 111 trials
showed that anticoagulation to an INR of 1.5-3.0 is safe and effective,
referencing a 1994 review article to support this statement. SPAF 111 was
not published until 1996 (1), so the reference is presumably to SPAF 11
(2). The target for anticoagulation in BAATAF (3) was a prothrombin time
ratio of 1.2-1.5 (corresponding roughly to an INR of 2.0-3.0), while in
SPAF 11 it was a PTR of 1.3-1.8 (roughly an INR of 2.0-4.5). SPAF 111
showed that, in high risk patients, fixed dose warfarin (initial INR 1.2-
1.5) plus aspirin was less effective than adjusted dose warfarin (INR 2.0-
3.0). A subsequent trial of fixed dose warfarin was stopped early in the
light of SPAF 111. At stopping, there was a non-significant trend
favouring adjusted dose warfarin (INR 2.0-3.0) (5). In patients with
atrial fibrillation treated with warfarin, current evidence suggests that
the best ratio of benefit to risk is achieved when the target INR is 2.0-
3.0 (5).
1. Stroke Prevention in Atrial Fibrillation Investigators. Adjusted-
dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for
high-risk patients with atrial fibrillation:Lancet 1996 Sep
7;348(9028):633-8
2. Stroke Prevention in Atrial Fibrillation Investigators. . Warfarin
versus aspirin for prevention of thromboembolism in atrial fibrillation:
Lancet 1994 Mar 19;343(8899):687-91
3. The Boston Area Anticoagulation Trial for Atrial Fibrillation
Investigators. The effect of low-dose warfarin on the risk of stroke in
patients with nonrheumatic atrial fibrillation.N Engl J Med 1990 Nov
29;323(22):1505-11
4. Gullov AL, Koefoed BG, Petersen P, Pedersen TS, Andersen ED,
Godtfredsen J, Boysen G. Fixed minidose warfarin and aspirin alone and in
combination vs adjusted-dose warfarin for stroke prevention in atrial
fibrillation: Second Copenhagen Atrial Fibrillation, Aspirin, and
Anticoagulation Study.Arch Intern Med 1998 Jul 27;158(14):1513-21
5. Lancaster T, Mant J, Singer D. Stroke prevention in atrial
fibrillation. BMJ 1997;314:1563-4.
Competing interests: No competing interests
The editorial paid so little attention to role of active drug treatment
As a 77 year old former sufferer from atrial fibrillation I was
surprised that the editorial paid so little attention to the role of
active drug treatment.
The editorial dwelled upon electroconversion and anti-coagulation
but did not mention any other medicaments which can be useful.
I began to have occasional episodes of AF at age 65 . At first,
single doses of verapamil stopped the attacks but as they became more
frequent I was advised to take daily prophylactic long-acting verapamil.
This worked, but I developed some ankle oedema (there is no mention of
this in the drug company's information but my GP told me that it is well
known).
At last, 3 years ago at age 74, a cardiologist colleague prescribed
for me FLECAINIDE, and on 100mg twice a day my heart has been in sinus
rythm ever since! Am I just lucky or are other AF sufferers being denied
the chance for simple
drug treatment?
David Vernon Thomas
Los Altos
California 94024
Competing interests: No competing interests