Derek Burnett
Derek Burnett is a Contributing Writer at Bottom Line Personal, where he writes frequently on health and wellness. He is also a contributing editor with Reader’s Digest magazine.
Somewhere between 3 million and 10.5 million Americans have atrial fibrillation, an erratic heartbeat caused by faulty electrical signaling in the heart. A-fib is especially prevalent in older adults. The age group 65 to 85 accounts for 70% of people with A-fib, with one in 10 people over age 80 developing the condition (this is partly due to age as an independent risk factor, and partly because older adults are more likely to have other conditions that are risk factors, such as high blood pressure and diabetes). Fortunately, advancements in medicine over the past several decades have led to multiple treatments for A-fib. But are they safe and effective for older adults? How long can an elderly person live with A-fib? Should their expectations regarding treatment be different from those of younger patients?
Because our risk of atrial fibrillation increases with age, it’s reasonable to wonder whether everyone should be screened for the condition after a certain age. But to date, screening has not been fully embraced by the U.S. medical community. While the American Heart Association finds the idea potentially useful for people 65 and up, the U.S. Preventive Services Task Force will not endorse screening until there is sufficient evidence that screening would not result in overtreatment at the population level.
For many elderly people, the diagnostic journey begins when their primary doctor notices an aberration when listening to their heartbeat during a routine office visit. Of course, many people also come to their doctors with a list of symptoms, including tightness in the chest, an inability to exercise, the feeling that their hearts are skipping a beat or double-beating, and frequent lightheadedness. A challenge in older people is sorting out some of those symptoms from the vagaries of normal aging.
Whichever way brings your symptoms to your doctor’s attention, the next step will be testing. Often you’ll undergo blood testing on your organ functions, a chest x-ray, and an ECG (electrocardiogram). You may also be given an exercise stress test and an echocardiogram. But what if your symptoms come and go intermittently and aren’t present during your doctor visit or during testing? If that’s the case, you may be given a device to wear at home to monitor your heart as you go about your daily life. You may have it on anywhere from a day to a month. It will pick up any anomalous rhythms and record any Afib episodes.
In a person with A-fib, the electrical impulses that control the contraction of the muscles in the heart go haywire, resulting in quivering of the walls of the organ’s upper chambers, called the atria. This rapid, erratic contraction puts the atria out of sync with the contractions of the heart’s lower chambers, called the ventricles. The heart no longer pumps blood efficiently, often causing symptoms such as dizziness, breathlessness, and fatigue. And the heart’s chambers no longer empty sufficiently, leaving behind blood that can pool and form clots which then travel to the brain, causing a stroke.
When doctors and patients work together to treat A-fib, they have two general concerns in mind—one is to address the heart rate or heart rhythm problems that produce symptoms, and the other is to lower the patient’s risk of stroke.
Most A-fib patients are put on medications to make their blood less likely to clot. While this is an effective way to reduce the chance of a clot forming in the heart and traveling to the brain to cause a stroke, it also increases the likelihood of unwanted bleeding events, including in the gastrointestinal tract and in the brain. The novel oral anticoagulant drugs (NOACs) used today are less likely to cause major bleeding events, but still must be carefully prescribed in elderly patients to find the right dosage to reduce stroke without encouraging hemorrhages. This is particularly true for elderly A-fib patients who also have coronary artery disease.
If a person is unable or unwilling to take anticoagulant medications, they may undergo a procedure known as left atrial appendage closure, or LAA. The left atrial appendage is a small pouch in the wall of the upper left chamber of the heart which is frequently the site of clotting. Doctors may sew this pouch closed, remove it, or plug it. While these are invasive procedures, they generally only require an overnight hospitalization.
Anticoagulant therapy addresses the risk of stroke, but other therapies seek to improve people’s lifestyles by keeping the heart from beating too rapidly or chaotically. There are two broad approaches, called rate control and rhythm control. As their names suggest, rate control attempts to regulate the speed of the heart’s beating, while rhythm control seeks to re-establish a stable, uniform heart rhythm.
The first-line approach in elderly patients is rate control (This is also often recommended in younger patients who don’t experience symptoms from their A-fib). The most effective way to get the heart rate under control is with beta-blocker medications such as metoprolol (Lopressor). As an alternative, calcium channel blockers such as diltiazem or verapamil may be used.
For some elderly patients, symptoms persist despite rate-control therapy. They and their doctors might then consider pursuing rhythm-control treatments. Unfortunately, rhythm control in the elderly is more problematic than rate control.
Typically, rhythm control is achieved through a process called cardioversion, in which the heartbeat is temporarily paused. When it resumes, it once again begins beating normally. This may be done with medication or via an electrical shock. Because electrical cardioversion requires sedation, it is less commonly recommended for the elderly.
After cardioversion, patients must take antiarrhythmic medications to maintain the steady heart rhythm achieved via cardioversion. While there are several antiarrhythmic drugs that can be prescribed for older patients, they should not be used in people with existing heart, kidney, or liver disease. They also interact poorly with many other medications frequently prescribed to the elderly, and they come with serious side effects including the creation of other arrythmias. Therefore, antiarrhythmics should only be given to elderly people under very careful monitoring.
Rhythm control may also be achieved through a procedure known as left atrial catheter ablation, in which doctors destroy a part of the heart tissue that is causing the irregular heartbeat. Studies show that the safety and efficacy of this procedure is similar in older and younger patients. It is considered a better choice for elderly patients than another procedure, called AV node ablation, in which the electrical connection between the upper and lower chambers of the heart is destroyed and replaced by an implanted pacemaker.
Studies have shown no survival benefit to rhythm control over rate control in elderly patients with at least one risk factor for stroke.
Statistically, atrial fibrillation dramatically decreases life expectancy in older adults. Unfortunately, 65% of male A-fib patients ages 55 to 74 will die within 10 years of diagnosis. That’s more than twice the mortality rate of men without atrial fibrillation. For women, the percentage of A-fib patients who die within 10 years is lower than that of men (58%), yet almost triple that of women without the condition (21%).
However, statistics are not destiny. You can give yourself the best chances of living a long and healthy life by pursuing a treatment plan along with lifestyle changes such as a heart-healthy diet, a physician-approved exercise regimen, stress reduction, smoking cessation, correcting any sleep disorders, and quitting alcohol. You should also address any other health problems that may be related to your atrial fibrillation, such as diabetes, high blood pressure, lung disease, and obesity.
