Arrhythmias in Older People: Focusing on Atrial Fibrillation. Epidemiology and impact on daily Life

Sammanfattning: Older people with arrhythmias comprise a large group requiring complex care, posing many healthcare challenges. Rapid growth of the older population demands a better understanding of the needs of this patient group. The aim of this thesis was to investigate arrhythmia prevalence, incidence, survival, and experiences from the perspective of a geriatric population (aged 60+ years), and to examine the feasibility of using the new wireless LTR ECG-BodyKom® device for arrhythmia screening. This thesis comprises four studies (I–IV) performed using data from the Swedish National Study on Aging and Care (SNAC). The results illustrate different perspectives regarding arrhythmias in the older general population. In Study I, 6904 subjects underwent ECG at baseline, of whom 3419 subjects (49.5%) of 66–105 years of age also underwent resting ECG at their 6-year follow-up visit. At baseline, there was a 4.9% prevalence (95% CI, 4.5–5.5) of atrial fibrillation (AF), and an 8.4% prevalence (95% CI, 7.7–9.0) of other arrhythmias, including ventricular premature complexes, supraventricular tachycardia, and supraventricular extrasystole. Additionally, 7.1% (95% CI, 6.5–7.7) exhibited a first or second degree AV block, and 1.3% (95% CI, 1.0–1.6) had a pacemaker-induced rhythm. Baseline arrhythmia presence did not significantly differ between men and women. The 6-year cumulative incidence of AF was 4.1% (95% CI, 3.5–4.9) or 6.9/1000 person-years (py) (95% CI, 5.7–8.0). Subgroup analyses revealed AF incidences of 9.9/1000 py (95% CI, 7.8–11.9) among men; 4.4/1,000 py (95% CI, 3.1–5.6) among women; 3.7/1000 py (95% CI, 2.6-4.7) in the 60- and 66-year age cohort; 8.9/1000 py (95% CI, 6.3–11.4) in the 72- and 78-year cohort; 20/1000 py (95% CI, 14.2-25.7) in the 81-, 84-, and 87-year cohort; and 18/1000 py (95% CI, 0.8–26.7) among those ≥90 years old. Incidences of AF, other arrhythmias, AV block, and pacemaker-induced rhythm were significantly higher among men, except in the oldest cohorts. Study II revealed that among 6904 persons (mean age, 73.9 years) the overall AF prevalence was 4.9%, which increased with age, except in the oldest subgroup. AF at baseline was associated with a hazard ratio (HR) of 1.29 (95% CI, 1.10–1.51) for death during the 10-year observation period. Cox regression analysis in persons with AF (n=341) revealed that men had a higher HR for death (1.57; 95% CI, 1.15–2.13) compared to women (P<0.01). CHA2DS2-VASc score was significantly associated with 10-year death (HR=1.29/score point; 95% CI, 1.10–1.51). A total of 146 participants (146%) reported any form of oral anticoagulant (OAC) use, and 14% reported OAC treatment with warfarin. Cox regression analysis of warfarin (33.6%) and ASA (66.4%), separately, revealed that warfarin was significantly associated with survival (P=0.031). Study III revealed persistent AF in 10% and paroxysmal AF in 5.5% of the population aged ≥66 years, with no differences between younger (66–80 years) and older (>80 years) subgroups. Our findings support LTR ECG-BodyKom® as a feasible method of screening for arrhythmias in older outpatient populations. This simple method requires little of the user, and participants reported high satisfaction with the equipment and a good overall experience wearing it. Study IV focused on geriatric experiences of living with arrhythmias. Interviews with older persons revealed one main theme: “ambivalence in the need of knowledge”. With regards to requiring lifelong medical treatment, participants expressed feelings of “it doesn’t matter, but it does matter” and “being in the hands of the healthcare system”. The participants lacked sufficient knowledge about their condition, leaving them with poor insight into their medical treatment, which, in turn, affected their daily life. They had thoughts and questions about their medical treatment, but had no opportunity to discuss these questions due to a lack of follow-up from the healthcare system. The findings of this thesis contribute to the knowledge regarding increasing arrhythmia occurrence in the older population, and the high number of untreated cases of AF. Furthermore the results demonstrate that AF is associated with increased mortality, and highlight sex-related differences in AF incidence. In line with findings from Europe and the USA, our findings show that AF incidence rapidly increases with advancing age. This thesis also highlights the present lack of knowledge and the need for follow-up and information regarding AF in the oldest old population.