EvidenceAlerts

Dalgaard F, Pallisgaard JL, Nume AK, et al. Rate or Rhythm Control in Older Atrial Fibrillation Patients: Risk of Fall-Related Injuries and Syncope. J Am Geriatr Soc. 2019 Jul 24. doi: 10.1111/jgs.16062. (Original study)
Abstract

OBJECTIVES: Management of atrial fibrillation (AF) with rate and/or rhythm control could lead to fall-related injuries and syncope, especially in the older AF population. We aimed to determine the association of rate and/or rhythm control with fall-related injuries and syncope in a real-world older AF cohort.

DESIGN: A retrospective cohort study.

SETTING: Danish nationwide administrative registries from 2000 to 2015.

PARTICIPANTS: A total of 100 935 patients with AF aged 65 years or older claiming prescription of rate-lowering drugs (RLDs) and/or anti-arrhythmic drugs (AADs) were included. We compared the use of rate-lowering monotherapy with rate-lowering dual therapy, AAD monotherapy, and AAD combined with rate-lowering therapy.

MEASUREMENTS: Outcomes were fall-related injuries and syncope as a composite end point (primary) or separate end point (secondary).

RESULTS: In this population, the median age was 78 years (interquartile range [IQR] = 72-84 y), and 53 481 (53.0%) were women. During a median follow-up of 2.1 years (IQR = 1.0-5.1), 17 132 (17.0%) experienced a fall-related injury, 5745 (5.7%) had a syncope, and 21 093 (20.9%) experienced either. Compared with rate-lowering monotherapy, AADs were associated with a higher risk of fall-related injuries and syncope. The incidence rate ratio (IRR) for the composite end point was 1.29 (95% confidence interval [CI]: 1.17-1.43) for AAD monotherapy and 1.46 [95% CI = 1.34-1.58] for AAD combined with rate-lowering therapy. When stratifying by individual drugs, amiodarone significantly increased the risk of fall-related injuries and syncope (IRR = 1.40 [1.26-1.55]). Compared with more than 180 days of rate-lowering monotherapy, a higher risk of all outcomes was seen in the first 90 days of any treatment; however, the greatest risk was in the first 14 days for those treated with AADs.

CONCLUSION: In AF patients aged 65 years and older, AAD use was associated with a higher risk of fall-related injuries and syncope, and the risk was highest within the first 14 days for those treated with AADs. Only amiodarone use was associated with a higher risk.

Ratings
Discipline Area Score
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Cardiology 6 / 7
Internal Medicine 6 / 7
Geriatrics Coming Soon...
Comments from MORE raters

Family Medicine (FM)/General Practice (GP) rater

One would expect the risk to be higher in the first 2 weeks, but the fact that amiodarone control heightens the risk may be worth sharing.

General Internal Medicine-Primary Care(US) rater

Although an observational study, this is a true population-based cohort. The significance is that this may move prescribers away from the current conventional wisdom of similar outcomes toward avoidance of anti-arrhythmic meds for most patients. There may always be patients who need such meds, however, with the increased availability of ablation, use will likely decline.
Comments from EvidenceAlerts subscribers

No subscriber has commented on this article yet.