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1 I have nothing to disclose.

2 Atrial fibrillation in octogenarians and beyond. The magnitude of the problem Etienne Aliot University of Nancy France

3 Population ageing

4 World Population Ageing Age> 80 years x 5.5 Population Div., DESA, United Nations

5 Adults with AFib (millions) The AF Epidemic Due to population ageing, AF prevalence should double in Age and sex-adjusted AF increased from 3.04 to 3.68 per 1000 patient years from 1980 to 2000 Olmsted County Data Miyasaka,CIRC 2006 Go:JAMA, Year

6 AF prevalence 2/3 of AF patients are >75 years old In France, to 1 million patients : > 75 years old Arch Cardiovasc Dis Feb;104(2): Charlemagne A, Arch Cardiovasc Dis. 2011

7 Epidemiology of AF in France deaths from AF in 2000 vs deaths in 2007 Charlemagne A, Arch Cardiovasc Dis 2011

8 AF and comorbidities ATHENA SPORTIF AFFIRM ALPA ATRIA Hypertension CHD HF Diabetes 17 ATHENA : N Engl J Med 2009;360: SPORTIF : Lancet ;362: ATRIA :JAMA. 2001;285(18): AFFIRM : N Engl J Med 2002;347: ALPHA: Circulation ;99:

9 Symptoms Potential problems for the patient and the society Thromboembolism & stroke LIGHT- HEADEDNESS PALPITATIONS SYNCOPE DYSPNEA FATIGUE CHEST PAIN AF may also be asymptomatic Heart failure Hospitalisation Disability Death

10 AF increases patients risk of death and CV outcomes Renfrew/Paisley Rate ratio (95% Confidence Interval [CI])* All-cause mortality CV events Women n=8,354 Fatal or non-fatal stroke Heart failure All-cause mortality CV events Men n=7,052 Fatal or non-fatal stroke Heart failure * Adjusted for age; follow-up 20 years Stewart S, et al. Am J Med 2002;113: CV events: death or hospitalisation

11 Stroke is the most common and devastating complication of AF The incidence of all-cause stroke in patients with AF is 5% per year 1 AF is an independent risk factor for stroke 2 AF increases the risk of stroke ~5- fold 2 ~15% of all strokes in the U.S. are caused by AF 1 The risk for stroke increases with age 1 Stroke risk persists even in asymptomatic AF Annual stroke rate (%) Permanent AF Intermittent AF Low risk Moderate risk High risk 1. Fuster V, et al. Circulation 2006;114:e257-e Wolf PA, et al. Stroke 1991;22: Page RL, et al. Circulation 2003;107: Hart RG, et al. J Am Coll Cardiol 2000;35:183-7.

12 AF main complication in the elderly : STROKE 8% * Non treated patients in randomized studies:afasak, SPAF, BAATAF,CAFA, SPINAF. 12

13 AF and mortality in hospitalized elderly patients Survival 1,0 N= 331 Mean age 85 ± 7 years 0,8 0,6 0,4 0,2 0,0 Sinus rhythm Atrial fibrillation RR mortality = 2.40 ( ; p<0.001) Days - Traditional risk factors are not accurate predictors of overall mortality - AF seems to be a major risk marker - Early detection of enlarged LA and ACE inhibitor prescription may be of interest Dec;207(2): Vesin C et al, Atherosclerosis

14 AF and risk of incident dementia (meta analysis) N= Mean age range 61/84 years F-up 7.7 ± 9.1 years AF patients should periodically be screened for dementia Santangeli P et al, Heart Rhythm in press

15 AF and comorbidity in elderly Baseline characteristics in Linköping municipality (N = Age 85 years) Elderly patients with AF do not have increased comorbidity do not report poorer QoL nor do they have an overall higher health care consumption compared to subjects without AF! Radholm K et al,arch of Gerontology and Geriatrics

16 QoL in an elderly population with AF compared with general population norms (n = 1 762, 75 years and over) Secondary analysis of data from the Birmingham AF Treatment of the Aged study No significant reduction in the generic QoL, once disability has been taken into account Treatments stategies should focus on complications prevention Roalfe AK et al, Europace 2012

17 Symptomatic -v- Asymptomatic AF Cardiovascular Health Study (n=5201) Prevalence of AF (%) Asymptomatic Symptomatic All Symptomatic Silent Atrial Fibrillation Age Group Its only the tip of the iceberg Edward J Smith, Captain of the Titanic Furberg et al, 1994

18 Why are Patients with AF asymptomatic? All may apply to old patients. Personality - stoic Inactive elderly patients Permanent AF Masked by other symptoms (CHF) Symptoms reduced by therapy (drugs, device, ablation, placebo) Improvement over sinus node disease (improved rate and chronotropic competence)

19 Subclinical AF and the risk of stroke Risk of AF HR:5.56 n = Mean age 76 ±7 years PM or ICD recently implanted Risk of stroke HR:2.49 Occurrence of subclinical AF is associated with development of clinical AF and with and increased risk of subsequent stroke Healey JS et al, for the ASSERT investigators, NEJM 2012

20 70% of the cost of AF management is driven by inpatient care and interventional procedures EUROHEART SURVEY ( ) Work loss Consultations Inpatient care Interventions Drugs Diagnostics 100% 80% 60% 40% 20% 0% Greece Italy Poland Spain Netherlands Ringborg et al. Europace 2008

21 Over half the costs of AF in France is due to hospitalisation COCAF Hospitalisations Drugs Consultations Distribution of cost of care in AF 9% 8% 2% 23% 6% Further investigations Paramedical procedures Loss of work 52% The mean annual cost of AF per patient in France is 3,209 Multiplied by the number of AF patients in France per year = 2.5 billion euros, driven mostly by hospitalisation Le Heuzey J-Y,et al. American Heart J 2004.

22 Total AF cost burden in 5 EU countries approximated at 6.2 billion euros Euro Heart Survey 1 Greece Italy Poland Spain Netherlands Mean costs of inpatient admission of an AF patient Mean costs incurred on an annual basis Estimated total annual cost 1,363 5,252 2,322 6,360 6,445 1,507 3,225 1,010 2,315 2, M 3,286M 526M 1,545M 554M 6.2 billion The mean annual cost per patient in France is 3,209 (COCAF study) 2 Multiplied by the number of AF patients in France per year = 2.5 billion Euros, driven mostly by hospitalisation 1. Ringborg A, et al. Europace 2008; 10: Le Heuzey J-Y, et al. American Heart J 2004;147:121 6.

23 Specjficity of AF in the elderly : «frailty evaluation» Décision du traitement anti-thrombotique Frailty Risk of fall Cognitive status Autonomy Co morbidities Renal function Depression Poly medications Nutrional state

24 HAS-BLED score (peu adapté au sujet âgé) HAS-BLED Score Hémorragies 100 pts/ an 0 1,13 1 1,02 2 1,88 3 3,74 4 8,70 Woman,85 years,, cognitive pb,falls, clearance 36mlmn,créat=112 umol Score=1 European Heart Journal 2010;

25 Score HEMORRHAGE (more specific,validated in patients>80 years) Score Hemorrhages points Hepatic or renal disease 1 Ethanol abuse 1 Malignany 1 Older age (> 75) 1 Reduced platelet count 1 Rebleeding risk 2 Hypertension (uncontrolled) 1 Anemia 1 Genetic factory (CYP 2C9) 1 Excessive fall risk or neuro-psychiatric disease 1 Stroke 1 Score HEMORRHAGE Hemorraghes in 100 patient-year on warfarine (%) Woman,85 years,, cognitive pb,falls, Clearance 36ml/mn,créat=112 umol Score=4 (Am Heart J 2006)

26 Conclusions - AF is mainly a disease of the old people. - AF is a marker of frailty in the elderly. - Management of AF in the elderly is «global»ie nutritive state,cognitive state,risk of falls,comorbidities etc.. - The magnitude of AF in the elderly emphasizes the importance of targeting therapy that provides clinical(ex:role of the antithombotic agents in stroke prevention++) and economic advantages.

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28 AF may emerge along the cardiovascular continuum and reflect disease evolution AF = marker of frailty in the elderly Remodelling Ventricular dilation MI Heart failure Atherosclerosis and left ventricular hypertrophy End-stage microvascular and heart disease Risk factors (diabetes, hypertension) Atrial fibrillation Death