Review
Atrial Fibrillation in Long Term Care

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Abstract

Increasing age is a potent risk factor for the development of atrial fibrillation (AF), as well as for incident stroke in patients with AF. The prevalence of AF in long term care facilities ranges from 7.5% to 17%, and such patients often present management challenges due to heightened risk for both stroke and bleeding complications related to thromboprophylaxis. This article reviews the diagnosis and management of AF in long term care. In general, patients with minimal symptoms can be managed with rate-control medications and anticoagulation. Patients with persistent symptoms and impaired quality of life despite adequate rate-control should be considered for cardioversion and antiarrhythmic drug therapy aimed at maintaining sinus rhythm. A small percentage of patients who do not respond to rate-control or rhythm-control interventions may be candidates for a catheter-based or surgical ablative procedure. In most older adults, the benefits of systemic anticoagulation in reducing the risk of stroke outweigh the risk of serious bleeding; therefore, anticoagulation is indicated in the majority of older AF patients, including nursing home residents. Although warfarin remains the preferred agent for stroke prophylaxis in the long term care setting, primarily due to very limited experience with the newer agents dabigatran, rivaroxaban, and apixaban, it is likely that the use of these newer drugs will increase as additional data accumulate documenting their safety and efficacy in AF patients of advanced age.

Section snippets

Symptoms and Signs

Although no studies have specifically examined symptoms and signs of AF in NH residents, clinical experience reveals that manifestations of AF are highly variable. Many patients are asymptomatic or minimally symptomatic. Others describe palpitations, fatigue, impaired exercise tolerance, shortness of breath, or chest discomfort. Acute or worsening heart failure is common in older patients with AF and rapid ventricular response rates, and an associated small to moderate rise in cardiac biomarker

Management

The primary objectives of therapy for AF are to alleviate symptoms and to reduce the risk of thromboembolism. The most common questions that arise in managing older adults with AF are whether to attempt to maintain sinus rhythm and whether to prescribe anticoagulation.

Recommendations

Given that NH residents comprise an extremely heterogeneous population, management of AF (indeed, of all conditions) must first and foremost be individualized, taking into consideration prevalent comorbidities, overall health and functional status, prognosis, goals of care, and personal preferences. In patients with adequate cognitive function, it is appropriate to discuss the risks and benefits of the various therapeutic options in accordance with the process of shared decision-making.

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    The author has no conflicts of interest relating to this article.

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