Curiculum Vitae

 Nama : dr. H. Sjarif Subijakto, Sp.JP(K) FIHA

 TTL : Surakarta, 28 Nopember 1967
 Pekerjaan: SMF Kardiovaskular RSUD Bahteramas Prov. SULTRA
 Pendidikan:
1. FK UGM Lulus Tahun 1992
2. Spesialis Jantung dan Pembuluh Darah FKUI tahun 2004
3. Intervensi Kardiologi FK UNDIP tahun 2015
 Istri : drg. RA. Liliek Hariyani LS
 Anak :
1. Pramudya Bagas Syahputra
2. RA. Lisya Anggraeni S
3. Rubiyantoro Risky Syahputra
Arrhythmia in
Elderly
Management
Approach
SJARIF SUBIJAKTO MD
 ELDERLY PATIENTS, BACKGROUND

 Elderly people constitute a larger segment of

the population today.
 In 1900, only 4% of the population in the
United States was 65 or older.
 In 2000 representing nearly 13% of the
population.
 By 2030 elderly people are expected to
constitute over 20% of the U.S. population
 Pathological Alterations
 It is important to distinguish between the normal, physiological
consequences of aging on cardiac electrophysiology and the
abnormal, pathological alterations.

 Human aging is a global issue with important implications for

current and future incidence and prevalence of cardiac arrhythmias,
including atrial fibrillation, sudden cardiac death, and bradycardia
requiring pacemaker placement, all increase exponentially after the
age of 60.

 Guidlines in management of heart rhythm disorders in elderly

patients ( age more than 75 years) could influenced by geriatric
pathophysiological factors.
 Pathological Alterations
 Aging is associated with electrical and structural
changes of the myocardium.
 The response to catecholamines is also reduced
and the baroreceptor reflex activity is blunted.
 These aspects conceivably affect the response to
antiarrhythmic drugs in the elderly.
 Furthermore, physiological parameters change
in older age, affecting the pharmacokinetics of
drugs.
 Pathological Alterations
 The age-related cardiac changes include fibrous infiltration of the
conduction system, and loss of natural pacemaker cells and these
changes could have a profound effect on the development of
arrhythmias.
 Individuals 65 years of age or older are living longer but with a variety of
chronic diseases including heart failure (HF). However, these symptoms
can also exist in people experiencing an atrial or ventricular arrhythmia
(atrial and ventricular ectopy) can result in significant symptoms, which
can impact quality of life (QoL).

 The age-related cardiac electrophysiological changes include up- and

down-regulation of specific ion channel expression and intracellular
Ca2+ overload which promote the development of cardiac arrhythmias.
 FALLS AND SYNCOPE IN ELDERLY

 Arrhythmias
 Bradycardias
 Supraventricular tachycardia
 Ventricular tachycardia
 The insertionof dual-chamber pacemakers in
nonaccidental fallers with cardioinhibitory
carotid sinus syndrome significantly reduces
falls and syncope.
SupraventricularArrhythmias.
Management in Elderly

 SVT in general is any tachyarrhythmia that requires atrial and/or

atrioventricular (AV) nodal tissue for its initiation and
maintenance. It is usually a narrow-complex tachycardia that has
a regular, rapid rhythm; exceptions include atrial fibrillation (AF)
and multifocal atrial tachycardia (MAT). Aberrant conduction
during SVT results in a wide-complex tachycardia.

 The most common mechanism identified is reentry

Anticoagulant in AFib

 Evaluation of risk of stroke in elderly use

CHA2DS2VASc score.
 Not prescribing anticoagulant on 85-92 years.
 88 % presrcibing anticoagulant on older than
75 years.
 Reasons not prescribing anticoagulant in
elderly were high risk for bleeding (72%),
patient or family’s choice(48%), decreased
renal function (32%), decreased liver function
(14%).
Anticoagulant in AFib

 For long-term anticoagulant VKA was still the

first choice in elderly AF (62%). NOACs (38%),
none chosen single or double antiplatelet
therapy or LMWH heparin for elderly AF.
 If Ablation was employed for AF, VKA,
NOACs, and aspirin were chosen prior the
procedure. After AF ablation VKA and NOACs
were chosen for anticoagulant therapy.
LMWH and antiplatelet therapy had not
chosen.
ABLATION THERAPY

 Ablation therapy in elderly patients answered by

49 centres, with averege percentage:
atrioventricular nodal re-entrant tachycardia
ablations in 18,8%. His bundle ablations 17%. AF
ablation 18,6 %. Tachycardia/flutter ablations
27.7% and ventricular arrhhythmia ablations in
10,7%.
 AF ablation in elderly patients in 18,4 of centres ,
compared with supraventicular tachycardias
(89,8%) and ventricular arrhythmias (65,3%).
Antiarrhythmic Drugs
 Antiarrhythmic drugs will remain the first-line approach in most patients
for the prevention or suppression of atrial and ventricular arrhythmias.
 Treatment of in elderly patients is often complicated and clinical
dilemma may often be encoutered because od decreasing physiological
funtions, multiple comorbidities, polypharmacy, and side effects.

 Adverse effects of antiarrhythmic drugs proarrhythmic effects and other

side effects, may frequently occur in elderly patients. Flecainide and
amiodaron have raised more concerns from physicians, while attention
also been drawn to dronaderon, beta blocker, calsium channel blocker,
and digitalis.

 As a rule of thumb, a 50% reduction in the starting dose of

antiarrhythmic drugs compared with younger patients appears a wise
approach in elderly patients.
Antiarrhythmic Drugs

 The selection of antiarrhythmic drugs in the

elderly is predominantly determined by factors
such as the treatment target, assumed patient
compliance, possible drug interactions, co-
morbidity, and renal and liver function.
 Efficacy and safety monitoring should take into
account symptoms, ECG findings, rhythm
recordings, plasma drug concentrations and
other laboratory parameters.

PACEMAKER PLACEMENT

 Increased frequencies of supraventricular and

ventricular ectopies have been reported in elderly
patients. Additionally, elderly patients atrial
fibrillation, sudden cardiac death, and
bradyarrhythmias requiring pacemaker placement.

 There is also a remarkable age-related increase in

bradyarrhythmias, both in sinus nodal dysfunction
and in atrioventricular (AV) blocks. The incidence of
first time pacemaker implantation increases
substantially after the age of 60, peaking in the
seventies.
Issues with polypharmacy in Elderly

 Issues with polypharmacy: Drug-drug

interactions. In addition to the above,
polypharmacy is an important problem in the
elderly.
 Both the prevalence of adults with prescriptions
and the number of prescriptions per person
increase with age. More than 75% of elderly
people in the community use one or more
medications, with an average of eight
prescriptions per elderly patient

Risk of bleeding in the elderly patient.

 Deterioration in sinus and AV nodal function in the elderly

increases for developing significant bradycardia and heart
blocks. Also, the increase in sensitivity to anticoagulating agents
heightens the risk of bleeding in the elderly patient.

 The age-related changes in pharmacodynamics include reduced

sensitivity to blockers increased sensitivity to Class I
antiarrhythmic drugs in terms of sinus nodal function and
electrical impulse conduction. Also, antiarrhythmic drugs have
greater avidity in binding to cardiac tissue in patients with
ischemic heart disease and cardiomyopathy.

 Finally, impaired homeostatic mechanisms increase the risks of

potential adverse drug effects such as orthostasis, urinary
retention,constipation, falls, and bleeding.
Disruption of intracellular Ca2+
regulation in Elderly
 Aging is a primary risk factor for cardiac
arrhythmias: disruption of intracellular Ca2+
regulation as a key suspect.
 Dysregulation of intracellular calcium within the
heart is likely to play a key role in initiating and
perpetuating these life-threatening events.
 Cardiac calcium regulation significantly change with
advancing age – changes that could produce
electrical instability.
 Further development of knowledge of the
mechanisms underlying these changes will allow us
to reduce the incidence of arrhythmias in the elderly.
CONCLUSION
 What do we need to know about antiarrhythmic drug therapy in
elderly patients?
 Elderly patients are consumers of medications, which increases
the risk of drug-drug interactions. Moreover, the elderly are
subject to significant age-related physiological changes that may
alter the effects of individual drugs.
 The second thing to know is the antiarrhythmic drugs. Age-
related alterations in drug pharmacokinetics, in hepatic
metabolism, and in renal elimination.
 The third thing to know is that the use of antiarrhythmic drugs in
elderly patients must be individualized. Potential drug-drug and
drug-disease interactions are common . All these issues may
have a significant impact on the health-related quality of life in
the elderly
THANK YOU
 ATRIAL FIBRILLATION

 In a randomized study it was found that patients

aged ‡65 years with atrial fibrillation had better
survival with rate control than with rhythm control.
 Elderly patients at high risk of atrial fibrillation. Risk
of stroke in patients with excessive atrial ectopy and
short atrial run, Atrial ectopy is a predictor of AF.
 But excessive supra ventricular ectopic activity
(defined as the presence of either ≥ 30 premature
atrial contractions/hour daily or any runs of ≥ 20
premature atrial contractions) is associated with an
increased risk of ischemic stroke beyond manifest
AF.
 Anticoagulant in AFib
 In elderly, premature atrial contractions detected on
the routine screening ECG are associated with an
increased risk of ischemic stroke.

 Elderly patients with interatrial block (IAB) have an

increased risk of dementia and stroke.

 In patients without documented arrhythmias,

anticoagulant drugs could probably be used in the
presence of high CHA2DS2VASc, supraventricular
ectopic activity, and advanced IAB with high risk of
atrial arrhythmias (Bayes syndrome) to prevent
cognitive impairment and embolic stroke.
 Anticoagulant in AFib
 The evidence that AF is not the final cause of
stroke, just an important risk maker to
prescribe anticoagulation to elderly patients.
 Interatrial block (IAB) is frequent in elderly
patients that are treated with cardiac surgery.
That elderly patients with IAB, would have an
increase in the rate of postoperative AF
compared to patients without IAB. These
could influence the decision to anti-coagulate
or not these patients.
 Anticoagulant in AFib

 Even in the absence of documented

arrhythmias, the risk of AF is probably
enough to merit anticoagulation in elderly
patients with high CHA2DS2VASc-score,
excessive atrial ectopy or short atria runl, and
advanced IAB.
 These three variables should be included in
the assessment of patients who undergo
cardiac surgery.
 Antiarrhythmic Drugs

 Unexpected adverse effects may occur when

antiarrhythmic drugs are administered to
elderly patients.
 In elderly patiens arrhytmias: flecainide in
52%, amiodaron in 30%, digitalis in 13%,
dronaderon in 11%, beta bloker in 9%,
calsium channel bloker in 16%, adenosin in 8
%.