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Key words: Age, atrial fibrillation, elderly, Middle-east, trends.
Correspondence: Jassim Al Suwaidi, MB, ChB, FACC, FSCAI, FESC, Department of Adult Cardiology, Heart Hospital, Hamad Medical
Corporation (HMC), P.O Box 3050, Doha, Qatar.
E-mail: jha01@hmc.org.qa; jalsuwaidi@hotmail.com
Received July 12, 2012; accepted in revised form October 16, 2012.
First published ahead of print November 26, 2012 as DOI 10.3275/8757
Effect of age on treatment, trends and outcome
of patients hospitalized with atrial fibrillation:
insights from a 20-years registry in a
middle-eastern country (1991-2010)
Aging Clinical and Experimental Research
Amar M. Salam1, Hajar A. AlBinali1, Essa M. Al-Sulaiti2, Abdul Wahid Al-Mulla1,
Rajvir Singh1and Jassim Al Suwaidi1
1Cardiology and Cardiovascular Surgery Department, 2Geriatric Department, Hamad Medical Corporation,
Doha, Qatar
ABSTRACT. Background: Most studies on atrial fib-
rillation (AF) epidemiology, treatment, and outcomes
have included mainly Caucasians patients. The world
literature on AF in other ethnicities is very limited par-
ticularly in the elderly. Aims: The aim of this study was
to compare the clinical characteristics, treatment and
outcome of elderly and younger patients hospitalized
with AF in a Middle-Eastern country and examine
the trends of AF etiologies over a 20-year period.
Methods: A retrospective analysis of a prospective
registry of all patients hospitalized with AF in Qatar
from 1991 through 2010 was made. Patients were
divided into three groups; group 1: patients ≤50 years
old, group 2: patients between 51 and 70 years old, and
group 3: patients >70 years old. Clinical characteristics,
management, and outcomes of AF patients were com-
pared according to age. Results: Between the year
1991 and the end of 2010, a total 3848 consecutive pa-
tients were admitted with AF. One thousand three
hundred and forty-five patients were ≤50 years, 1759
were between 51 and 70 years and 744 patients were
>70 years old. Elderly patients were more likely to
have hypertension and chronic renal impairment. There
was a higher prevalence of associated coronary artery
disease and aortic stenosis in elderly patients with a low-
er left ventricular ejection fraction than the younger age
groups. A lower use of anticoagulation in the elderly
group was observed but there was no underuse of oth-
er evidence-based medications. The older AF patients
had significantly higher in-hospital mortality and stroke
rates with no significant changes in mortality trends
over the 20 years of study. An increasing trend of the
associated acute coronary syndromes, hypertension
and diabetes mellitus prevalence was observed in the el-
derly group. Conclusion: Anticoagulation remains un-
derutilized in elderly patients with AF despite proven ef-
ficacy and increasing trends of cardiovascular comor-
bidities. The current study underscores the urgent
need for prospective studies to investigate warfarin
contraindications, relative warfarin efficacy and bleed-
ing risks in our region to help guide healthcare providers
in warfarin prescribing in this frail patient population
and consequently reduce the risk of AF-related dis-
abling strokes and mortality.
(Aging Clin Exp Res 2012; 24: 682-690)
©2012, Editrice Kurtis
INTRODUCTION
Atrial fibrillation (AF) is the most common arrhythmia
encountered in clinical practice accounting for approxi-
mately one-third of hospitalizations for cardiac rhythm dis-
turbances (1, 2). It has long been established that AF is a
disease of aging with AF incidence doubling with each
decade of life (3). Studies have estimated that the annual
incidence of AF per 1000 person-years to be 1.9 in
women and 3.1 in men aged <65 years, but exceeds 32
per 1000 person-years in patients aged ≥80 years. Age-
related declines in vascular compliance, increased popu-
lation longevity, and the increasing prevalence of car-
diovascular disease in older persons have led to an ex-
panding AF epidemic in the developed world (2). To
date, most studies on AF epidemiology, treatment, and
outcomes have been performed in North America and Eu-
rope involving mainly Caucasians patients (2-5) and while
682 Aging Clin Exp Res, Vol. 24, No. 6
©2012, Editrice Kurtis
FOR PERSONAL USE ONLY
Outcome of elderly patients hospitalized with atrial fibrillation
Aging Clin Exp Res, Vol. 24, No. 6 683
there are recognized ethnic differences in cardiovascular
risk profiles (6), the world literature on epidemiology of AF
in different ethnicities is limited (7), particularly concern-
ing elderly patients.
Herein we studied the presentation, treatment and
outcome of elderly patients aged >70 years who were hos-
pitalized with AF in a Middle-Eastern country over a 20-
year period and compared them to younger age groups.
MATERIALS AND METHODS
Study setting
Qatar is a small country with a population that has in-
creased from around 600,000 in 2001 (Census data) to
1.6 million in 2010 (Census data), consisting of Qatari and
other Middle-Eastern Arabs (<40%) as well as other ethnic
groups. The vast majority of non-Arabs are South Asians
mainly from India, Pakistan, Nepal and Bangladesh. This
study is based at Hamad General Hospital, Doha, Qatar.
This hospital provides inpatient and outpatient medical and
surgical care for the residents of Qatar; nationals and ex-
patriates where more than 95% of cardiac patients are be-
ing treated in the country, making it an ideal center for
population-based studies. The vast majority of heart failure
and acute coronary syndrome (ACS) patients (>95%) are
admitted to this hospital. Since the last decade of the
20
th
century, cardiovascular diseases are the leading cause
of morbidity and mortality in the country.
The Cardiology and Cardiovascular Surgery Database
at Hamad General Hospital was used for this study.
Data are entered on all patients admitted to Hamad
General Hospital with cardiac illnesses. A case report
form with a specific registration identification number for
each patient admitted to Hamad General Hospital with
cardiac illnesses was filled out by the assigned physician
who followed the patient hospital discharge. The inves-
tigation was approved by Hamad Medical Review Board
prior to data analysis. Data were collected from the
clinical records written by physicians at the time of pa-
tient’s discharge from the hospital according to prede-
fined criteria for each data point. These records have
been coded and registered at the cardiology department
since January 1991.
With the described prospectively-collected registry
database, all patients presenting with AF requiring hos-
pitalization in the 20-year period between 1991 and
the end of 2010 were retrospectively identified. Patients
with AF were compared according to age.
Ethics statement
Ethical approval from the Research Committee of
Hamad Medical Corporation was obtained before starting
collection of data for the study. The Ethics Committee
waived the need of informed consent because of its ret-
rospective analysis and the fact that the data were ana-
lyzed anonymously.
Definitions
AF was based on physician-assigned diagnoses and de-
fined as the presence of AF on electrocardiogram, during
the index hospitalization. Congestive heart failure (CHF)
was defined using the Framingham criteria (8). Acute
myocardial infarction was defined for this study according
to the World Health Organization criteria (9). Use of ad-
junct therapy during hospitalization was recorded for ev-
ery patient. The presence of diabetes mellitus was de-
termined by the documentation in the patient’s previous
or current medical record of a documented diagnosis of di-
abetes mellitus that had been treated with medications or
insulin. The presence of hyperlipidemia was determined
by the demonstration of a fasting cholesterol >5.2
mmol/L in the patient’s medical record, or any history of
treatment of hyperlipidemia by the patient’s physician.
Chronic renal impairment was defined as creatinine >1.5
upper normal range. The presence of hypertension was
determined by any documentation in the medical record
of hypertension or if the patient was on treatment by the
patient’s physician. Smoking history: Patients were divided
into current cigarette smokers, past smokers defined as
more than 6-month abstinence from smoking, and those
who never smoked.
Statistical analysis
Patients’ characteristics in the form of mean, standard
deviations and frequency with percentages were expressed
for interval and categorical variables, respectively. The
frequencies of categorical variables according to age were
compared using the Chi-square tests and Student’s t-tests
were used to compare continuous variables. Influential
variables for in-hospital mortality were adjusted to see
impact of age applying multivariate logistic regression
using enter method. Adjusted odds ratios (OR), 95% con-
fidence intervals, and p-values were reported. A p-value
≤0.05 was considered as statistical significant. All p-values
were the results of two-tailed tests. All data analyses were
carried out using the Statistical Package for Social Sciences
version 19.0 (SPSS Inc., USA).
RESULTS
Of the 41.453 patients treated during the 20-year
period between the year 1991 and the end of 2010, a to-
tal of 3848 consecutive patients were admitted with AF:
1345 patients were ≤50 years, 1759 were between 51
and 70 years and 744 patients were >70 years old.
Baseline clinical characteristics (Table 1)
A higher percentage of women was observed in the
older patients (groups 2 and 3 vs 1). The older the AF pa-
tient the more likely to have hypertension and chronic re-
nal impairment. Current smoking was more prevalent
among the younger age group. The incidence of con-
comitant diagnosis of ACS, prevalence of prior myocar-
©2012, Editrice Kurtis
FOR PERSONAL USE ONLY
A.M. Salam, H.A. AlBinali, E.M. Al-Sulaiti et al.
684 Aging Clin Exp Res, Vol. 24, No. 6
dial infarction, prior coronary artery grafting and aortic
stenosis were higher in the older age groups, while
rheumatic heart disease and prior diagnosis with atrial fib-
rillation were more prevalent in the younger age group.
The left ventricular ejection fraction was lower in the
older age groups.
Medications (Tables 1 and 2)
Prior to admission
At the time of admission, the older age groups were
more likely on β-blockers, calcium channel blockers, di-
uretics, angiotensin converting enzyme inhibitors
(ACEi)/angiotensin II receptor blockers (ARB), antiplatelet
agents, hydralazine, nitrates, digoxin and antiarrhyth-
mics when compared to the younger age group.
Admission
The older age groups were more likely treated with β-
blockers, calcium channel blockers, diuretics, ACEi/ARB,
hydralazine and inotropes, while the younger age groups
were more likely to be treated with antiarrhythmics.
Discharge
Older age groups were more likely prescribed calcium
channel blockers, diuretics, ACE/ARB, antiplatelet agents,
hydralazine, digoxin and antiarrhythmics. Patients >70
Age (yrs)
p
≤50 51-70 >70
n (%) 1345 (35) 1759 (45.7) 744 (19.3)
Patient characteristics at admission
Female gender, % 28.6 39 46.5 0.001
Race, %
Middle-Eastern Arabs 63 75.8 90.6
South Asians 22.2 13 2.8
Others 14.9 11.1 6.6 0.001
Cardiovascular risk factors, %
Hypertension 14.3 49.1 57.1 0.001
Diabetes mellitus 9.3 41.4 40.7 0.001
Current smoker 18.4 10.9 5.1 0.001
Chronic renal impairment 1.5 4.7 10.8 0.001
Dyslipidemia 5.3 12.4 10.1 0.001
Prior cardiovascular disease, %
Prior myocardial infarction 1.6 14 20.2 0.001
Prior coronary artery bypass grafting 0.6 5.2 7.1 0.001
Rheumatic heart disease 4.2 2.2 0.1 0.001
Other current cardiovascular diagnoses, %
Acute coronary syndrome 2.6 8.8 13.3 0.001
Aortic stenosis 1.6 2.3 3.6 0.01
Mitral regurgitation 5.1 6.1 6.7 0.30
Pulmonary hypertension 1.2 1.1 2.3 0.06
Preadmission medications, %
Beta-blockers 5.1 11.9 12.4 0.001
Calcium channel blockers 1.2 5.2 7.8 0.001
Diuretics 15.1 36 47.4 0.001
ACEi/ARB 2.5 13.4 15.9 0.001
Antiplatelet agents 10.2 35 43.5 0.001
Hydralazine 0.1 0.8 1.5 0.002
Nitrates 0.3 4.3 7.5 0.001
Digoxin 12.7 22.6 29.3 0.001
Antiarrhythmics 14.6 24.8 31.6 0.001
Left ventricular ejection fraction, % (mean±SD) 49±11 43±14.5 41±14 0.001
In-hospital outcome, n (%)
Death 19 (1.4) 82 (4.7) 58 (7.8) 0.001
Stroke 3 (0.2) 5 (0.3) 8 (1.1) 0.008
Data are expressed in percentage of patients unless stated. ACEi: angiotensin converting enzyme inhibitor; ARB: angiotensin II receptor blocker.
Table 1 - Atrial fibrillation patients’ characteristics and co-morbidities according to age.
©2012, Editrice Kurtis
FOR PERSONAL USE ONLY
Outcome of elderly patients hospitalized with atrial fibrillation
Aging Clin Exp Res, Vol. 24, No. 6 685
years were significantly less likely to be prescribed war-
farin at time of discharge compared to the other two age
groups.
Outcome (Table 1)
Older AF patients had significantly higher in-hospital
mortality and stroke rates when compared to the younger
age groups.
Trend of hospitalization and outcome (Table 3)
Over the 20-year period, the total number of patients
hospitalized with AF increased accompanied by an in-
crease in the mean age from 54.9 to 57.5 years. The in-
hospital mortality rate for the overall group was sta-
tionary ranging between 5.1 and 3.6%. It was however
significantly lower in the younger age groups com-
pared to the older age groups all through the study
duration.
Secular trends analysis showed that the associated
ACS, hypertension and diabetes mellitus prevalence was
trending higher in the elderly group while heart failure
prevalence was trending lower. There were no significant
differences in mortality trends in the elderly group while
stroke rate was higher. The use of warfarin as well as
acetylsalicylic acid (ASA) in the elderly group was signif-
icantly trending higher over the study period.
Table 2 - Treatment on admission and at discharge according to
age.
Age (yrs)
p
≤50 51-70 >70
On admission
Beta-blockers 22.4 25.5 19.5 0.001
Calcium channel blockers 4.8 12.3 14.1 0.001
Diuretics 17 39.1 53.8 0.001
ACE/ARB 11.7 33.8 38.3 0.001
Antiplatelet agents 69.7 75.6 75.3 0.001
Hydralazine 0.1 1.4 2.3 0.001
Inotropes 1.6 7.8 8.3 0.001
Antiarrhythmics 69.2 59.5 59 0.001
Digoxin 49.1 45 49.3 0.001
At discharge
Beta-blockers 15.8 18.1 16.9 0.24
Calcium channel blockers 5.1 15.5 17.1 0.001
Diuretics 18.1 42.3 56.5 0.001
ACEi/ARB 14.1 37.8 43.5 0.001
Antiplatelet agents 39.3 57.4 61.6 0.001
Clopidogrel 1.2 4.6 7.9 0.001
ASA 38.6 56.6 60.2 0.001
Warfarin 32.8 39.3 26.1 0.001
Antiarrhythmics 39.9 52.2 55 0.001
Digoxin 32.2 42.9 46 0.001
Data are expressed in percentage of patients unless stated. ACEi: an-
giotensin converting enzyme inhibitor; ARB: angiotensin II receptor blocker;
ASA: acetylsalicylic acid.
Years
p
1991-94 1995-98 1999-02 2003-06 2007-10
Total group trends
Total n 648 (16.8) 900 (23.4) 474 (12.3) 891 (23.1) 935 (24.3)
Mean age±SD, yrs 54.9±16 55.7±15 56±15.6 56±16 57.5±16 0.02
Female gender, n (%) 215 (33.2) 350 (38.9) 181 (38.2) 349 (39.1) 322 (34.4) 0.04
Death, n (%) 29 (4.5) 33 (3.7) 24 (5.1) 40 (4.5) 34 (3.6) 0.64
≤50 yrs, n (%) 4 (1.6) 5 (1.6) 3 (1.8) 4 (1.3) 3 (1.0)
51-70 yrs, n (%) 18 (6.1) 18 (4.1) 11 (5.2) 18 (4.6) 17 (4.0)
>70 yrs, n (%) 7 (6.5) 10 (6.9) 10 (10.9) 17 (9.4) 14 (6.4)
p-value 0.02 0.01 0.006 0.001 0.005
Elderly group trends
Number >70 yrs 107 145 92 180 220
Mean age±SD, yrs 78±6 77.5±5.8 77±6 78±6.8 77.8±8.7 0.86
Women, % 44.9 38.6 40.2 51.1 51.4 0.07
Mortality rates, % 6.5 6.9 10.9 9.4 6.4 0.57
Stroke rates, % 0000.6 3.2 0.01
Diabetes mellitus, % 32.7 32.4 37 46.7 46.8 0.009
HTN, % 49.5 45.5 54.3 67.8 60.9 0.001
ACS, % 8.4 6.9 9.8 14.4 20.5 0.001
Heart failure, % 40.2 32.4 39.1 30.6 23.2 0.009
Valvular HD, % 0.9 3.4 5.4 0.6 0.5 0.09
RHD, % 0000.6 0.5 0.78
Warfarin, % 3.7 20.7 22.8 28.9 39.5 0.001
ASA, % 47.7 57.9 54.3 63.9 67.3 0.001
Data are expressed in (percentage) of patients unless stated. HTN: hypertension; ACS: acute coronary syndromes; Valvular HD: valvular heart disease; RHD:
rheumatic heart disease; ASA: acetylsalicylic acid.
Table 3 - Secular trends of the total and elderly atrial fibrillation groups over the 20-year study period.
©2012, Editrice Kurtis
FOR PERSONAL USE ONLY
A.M. Salam, H.A. AlBinali, E.M. Al-Sulaiti et al.
686 Aging Clin Exp Res, Vol. 24, No. 6
group. The current study underscores the urgent need to
study elderly AF patients among various ethnicities.
Baseline characteristics
The prevalence of diabetes mellitus in the current
study is higher than that reported in any AF trial or reg-
istry regardless of age. This is consistent with the high
prevalence of diabetes mellitus in the Arab Middle-East in
general, and in Qatar specifically, and may in part explain
the relatively younger mean age of patients observed in
the study. Moreover, the prevalence of diabetes mellitus
among patients increased further in the latter years when
compared to the earlier years of the study regardless of
age. This increase reflects the worldwide epidemic of
diabetes mellitus, which is expected to get worse by
2030 particularly in Asia (10).
Our study also showed a significantly higher prevalence
of ACS as a concomitant diagnosis with AF in the elderly
group and it was associated with higher complication
rate. This finding is consistent with previous studies that
have shown that new onset AF was associated with in-
creased short- and long-term mortality in patients pre-
senting with ACS (11). Indeed ACS was a significant
predictor of mortality in our multivariate analysis.
Treatment
Our study also demonstrated the underutilization of
oral anticoagulants (OAC) in patients with AF espe-
cially in the elderly group despite the overwhelming
evidence supporting OAC for stroke prevention. This
finding is consistent with reports from other parts of the
world. For example a prospective cohort study by Hylek
et al. (12) reported that only 51% of hospitalized elderly
patients with AF were initiated on OAC. Additionally,
Bungard et al. reported the prescription of OAC to
patients with AF without contraindications to be between
15.2 and 78.8% (13). Furthermore, a cross-sectional
analysis from the Anticoagulation and Risk Factors in
Atrial Fibrillation (ATRIA) study cohort reported this
figure to be only 55% (14). We have not studied the rea-
sons behind underutilization of OAC in our group but re-
ported reasons include physicians’ underestimation of the
risk of stroke, overestimation of the risk of hemor-
rhagic complications, the frailty of elderly people, cog-
nitive impairment, poor compliance of monitoring and
treatment, falls risk, associated co-morbidity and con-
comitant medications (15) which may, indeed, play a role
in our observations.
On the other hand, ASA and clopidogrel were more
prescribed to our elderly patients as an alternative to
warfarin. ASA therapy has indeed been shown to de-
crease the risk of stroke in AF; however, ASA is not as
effective as warfarin in stroke prevention (16). Thus,
electing to use ASA instead of warfarin assumes that
ASA therapy offers a lower risk of intracranial hemor-
Multiple logistics regression analysis (Table 4)
Acute coronary syndrome presentation was associated
with increased risk of death. ACEi/ARB and β-blockers
administration at admission was associated with reduced
risk of death. Age alone was not a predictor of in-hospi-
tal mortality.
DISCUSSION
The current study using large data of unselected con-
secutive AF patients admitted over 20 years in a Middle-
Eastern country demonstrates important differences be-
tween older and younger patients in the clinical profile,
management and prognosis. Elderly patients were more
likely to have hypertension and chronic renal impair-
ment. There was also a higher prevalence of associated
coronary artery disease and aortic stenosis in elderly pa-
tients with a lower left ventricular ejection fraction than the
younger age groups. Consistent with previous studies,
we report a lower use of anticoagulation in the elderly
group but there was no underuse of other evidence-based
medications such as ACEi/ARBs and β-blockers when
compared to younger patients contrary to most other
published reports. The use of warfarin as well as ASA in
the elderly group was significantly trending higher over the
study period. The older age AF patients had significantly
higher in-hospital mortality and stroke rates with no sig-
nificant changes in mortality trends over the 20 years of
study. A higher trend of the associated ACS, hypertension
and diabetes mellitus prevalence was observed in the elderly
Table 4 - Multivariate predictors of in-hospital mortality.
Variable Adjusted OR 95% CI p
Age 1.01 0.98-1.05 0.50
Male gender 1.11 0.44-2.84 0.82
Acute coronary syndrome 4.36 1.77-10.74 0.001
Diabetes mellitus 2.22 0.86-5.72 0.10
Hypertension 0.69 0.25-1.90 0.47
Dyslipidemia 1.90 0.66-5.48 0.23
Chronic renal impairment 2.99 0.98-9.15 0.054
Current smoking 1.01 0.32-3.20 0.98
Prior MI 1.68 0.62-4.54 0.98
EF<35 1.96 0.79-4.89 0.31
ACEi/ARB* 0.19 0.05-0.63 0.007
Beta-blockers* 0.36 0.15-0.87 0.02
Antiplatelet agents* 1.00 0.27-3.74 1.00
Antiarrhythmics* 0.36 0.11-1.15 0.08
Digoxin* 1.10 0.22-5.40 0.91
Variables forced into model are: age, acute coronary syndrome (ACS), dia-
betes mellitus, hypertension, dyslipidemia, chronic renal impairment, current
smoking, prior myocardial infarction (MI), past rheumatic heart disease,
normal left ventricular ejection fraction (EF), angiotensin converting en-
zyme inhibitor (ACEi)/ angiotensin receptor blockers (ARB), β-blockers and
antiplatelet agents. *Administered on admission. OR: odds ratio; CI: confi-
dence interval.
©2012, Editrice Kurtis
FOR PERSONAL USE ONLY
Outcome of elderly patients hospitalized with atrial fibrillation
Aging Clin Exp Res, Vol. 24, No. 6 687
rhage (ICH) than warfarin therapy, which is supposed to
balances the lower efficacy for stroke prevention. How-
ever, among patients >75 years of age in the Birming-
ham Atrial Fibrillation Treatment of the Aged (BAFTA)
trial (17), there was no difference in the rates of ICH be-
tween ASA- and warfarin-treated groups with a goal in-
ternational normalized ratio (INR) of 2.0 to 3.0. On the
other hand, the Stroke Prevention in Atrial Fibrillation
II (SPAF II) trial (18) (goal INR of 4.5) and the Japanese
Nonvalvular Atrial Fibrillation-Embolism Secondary Pre-
vention trial (19) both found significantly higher rates of
ICH among warfarin-treated patients than among those
treated with ASA. These mixed results do not necessarily
support the decision to favor ASA therapy over warfarin
therapy when treating elderly patients with AF who
are at high risk for hemorrhagic complications but pro-
vide a legitimate basis for more frequent monitoring and
a search for alternative agents in this higher-risk age
group. Additionally, Pengo el al. (20) observed a low rate
of stroke and major bleeding in patients aged >75 being
managed in an anticoagulation clinic for primary stroke
prevention with low-intensity anticoagulation (INR 1.5-
2.0). Although this is an option to be considered for cer-
tain patients, further studies are required before such
lower than usually targeted INR (2-3) can be formally rec-
ommended.
Interestingly, our study showed lack of underutilization
of evidence-based medication in the elderly group. In
fact there was a significantly larger use of ACEi/ARB, di-
uretics, calcium channel blockers, digoxin and antiar-
rhythmics both at admission and at discharge. This find-
ing is contradictory to previous studies from other parts of
the world that reported older age to be significantly as-
sociated with suboptimal use of evidence-based medica-
tions when compared to younger age groups, even in
carefully monitored patients without apparent con-
traindications (21-23). This was not, however, translated
in improved survival and stroke rates, which were higher
in our elderly group.
Outcomes and trends
It was noted in our study that in-hospital mortality
was higher in the elderly group and that mortality was sta-
tionary over the 20-year study period. This was rather sur-
prising given the improvements in the recognition and
management of the co-morbid conditions associated with
AF, especially hypertension, heart failure, and coronary
artery disease that occurred over the years. To investigate
this further, we looked into the secular trends of co-
morbidities which could be responsible for that lack of sur-
vival improvement that was expected. Indeed we found a
significantly increasing prevalence of diabetes, hyper-
tension and ACS among elderly patients over the 20-year
study period. Further analysis confirmed that ACS was an
independent predictor of in-hospital mortality, which
may explain, at least in part, our observation of the lack
of mortality benefit.
Although we limited the analysis to in-hospital mor-
tality, our findings are not inconsistent with other re-
ports that showed lack of improvement in mortality
trends over longer periods in other parts of the world. For
example, Miyasaka et al. (24) studied mortality trends in
patients diagnosed with first AF resident of Olmsted
County, Minnesota, USA (years 1980 to 2000), and re-
ported that mortality risk was high, especially within the
first 4 months, but more importantly there was no evi-
dence of any significant changes over the 21 years in
terms of overall mortality, early or late mortality, or mor-
tality among patients without preexisting cardiovascular
disease.
Finally, although AF has been extensively studied pre-
viously in Caucasian patients and mostly in the elderly
(Table 5) (25-35), data on AF in other ethnicities are very
scarce, particularly Arabs. Our study enrolled 2857 Arabs
with AF for the first time from a Middle-Eastern country
thus bridging a gap in AF research.
Limitations of the study
Our study is constrained by the limitations of all stud-
ies of historical, observational design. Inaccuracies in
the diagnosis and coding of AF in routine data are well
recognized. Additionally, temporal changes in referral
and coding practices, in diagnostic accuracy, and in
awareness of AF as a diagnostic entity may have influ-
enced our findings. Other study limitations could include
missing data or measurement errors, possible confound-
ing by variables not controlled for, as this was an obser-
vational study. Our study focused on in-hospital outcome
and long-term data are not available. In addition, our
prospectively collected registry did not include data on pre-
vious history of cerebrovascular accidents and transient is-
chemic attacks, therefore CHADS
2
or CHADS
2
-VASc
scoring was not possible.
CONCLUSIONS
The results of this 20-year observational study in res-
idents of a Middle-Eastern country provide for the first
time insights into the characteristics, treatment prac-
tices, and in-hospital outcome among elderly patients
from Middle-Eastern Arab and South Asian ethnicities.
The study demonstrated that anticoagulation remains
underutilized in elderly patients with AF in our region de-
spite proven efficacy and increasing trends of cardio-
vascular comorbidities. The current study underscores
the urgent need for prospective studies to investigate
warfarin contraindications, relative warfarin efficacy and
bleeding risks in our region to help guide healthcare
providers in warfarin prescribing in this frail patient pop-
ulation and consequently reduce the risk of AF-related dis-
abling strokes and mortality.
©2012, Editrice Kurtis
FOR PERSONAL USE ONLY
A.M. Salam, H.A. AlBinali, E.M. Al-Sulaiti et al.
688 Aging Clin Exp Res, Vol. 24, No. 6
Author (ref.) Study Year of Number of Major Major conclusions
publication patients population/
ethnicities
studied
Bilato et al. (25) Prevalence, functional 2009 1599xItalian population Prevalence of AF at baseline was 7.4%
impact, and mortality (100%) and increased with advancing age, heart failure
of AF in an older Italian was associated with a five-fold risk of AF,
population (from the in subjects ≥65 years old, AF is strongly
Pro.V.A. study) associated with heart failure, is an independent
risk factor for mortality and, in the presence of
physical disability, could be considered a
measurement of disability severity
Furberg et al. (26) Prevalence of AF 1994 5201x94.7% whites, AF was diagnosed in 4.8% of women and in
in elderly subjects. 4.7% 6.2% of men at the baseline examination, and
(The Cardiovascular African-Americans prevalence was strongly associated with
Health Study) advanced age in women. Prevalence of AF was
9.1% in men and women with clinical
cardiovascular disease, 4.6% in patients with
evidence of subclinical but no clinical
cardiovascular disease, and only 1.6% in
subjects with neither clinical nor subclinical
cardiovascular disease
Lake et al. (27) AF and mortality in an 1998 1770xWestern Australians AF was positively associated with angina, history
elderly population (100%) of myocardial infarction and left bundle branch
block. Relative mortality in those with AF
compared with those without it was 1.92 for all
causes. The excess relative mortality declined
with increasing age for both women and men
Go et al. (28) Prevalence of diagnosed 2001 15,941 Caucasians (84.7%), Among persons aged 50 years or older,
AF in adults: national Hispanics or prevalence of atrial fibrillation was higher in
implications for rhythm latino (2.5%), whites than in blacks (2.2% vs 1.5%).
management and stroke African-Americans
prevention. The (3.6%)
AnTicoagulation and
Risk Factors in Atrial
Fibrillation (ATRIA) Study
Ruo et al. (29) Racial variation in the 2004 1373 Caucasians Compared with Caucasians, African Americans
prevalence of AF 1150, were younger (mean age 67 vs 74 yrs) and
among patients with African-Americans more likely to have hypertension and prior
heart failure. 223 diagnosed heart failure. African Americans had
The Epidemiology, less prior diagnosed coronary disease,
Practice, Outcomes, revascularization, hypothyroidism, or valve
and Costs of Heart replacement. AF was much less prevalent in
Failure (EPOCH) Study African Americans (19.7%) than Caucasians
(38.3)
Dang et al. (30) AF in a multiethnic 2004 737 Caucasians (16.4%), Compared to Caucasians, left ventricular
inpatient population Asians (11.1%), hypertrophy was more common in African-
of a large public hospital Hispanics or latino, Americans and Asians. At discharge,
(59.2%) Caucasians more frequently had coronary artery
African-Americans disease compared to hispanics, African
(10.3%) Americans, and Asians; cardiomyopathy was
less common in Caucasians as compared to
African Americans, Hispanics and Asians
Bush et al. (31) AF among African 2006 4060 Caucasians African Americans were more likely female and
Americans, Hispanics 3599 (90.1%), hypertensive and Hispanics had higher
and Caucasians. Hispanics or latino prevalence of cardiomyopathy. Survival was
The Clinical Features 132 (3.3%), better for rate control than rhythm control in
and Outcomes from African-Americans Caucasians, equivalent in African Americans
the AFFIRM Trial 265 (6.6%) and better for rhythm control in Hispanics
Novaro et al. (32) Meta-analysis comparing 2008 (94,785)
xCaucasians (93,050), Asians experiencing acute ischemic syndromes
reported frequency of AF Asians (1735) have a significantly lower frequency of AF
after acute coronary compared with whites
syndromes in Asians
vs whites
Shen et al. (33) Racial/Ethnic differences 2010 22,807 Caucasians (8.0%), AF is less prevalent in older non-white
in the prevalence of AF (5.3% of Asians (3.9%), individuals than whites. White race/ethnicity is
among older adults - 430,317) Hispanics or associated with significantly greater odds for AF
A cross-sectional study latino (3.6%), compared to blacks, Asians, and Hispanics,
African-Americans (3.8%)
after adjusting for comorbidities
Continues
Table 5 - Summary of atrial fibrillation studies compared to the current study.
©2012, Editrice Kurtis
FOR PERSONAL USE ONLY
Outcome of elderly patients hospitalized with atrial fibrillation
Aging Clin Exp Res, Vol. 24, No. 6 689
ACKNOWLEDGEMENTS
We wish to acknowledge members of the Department of Cardiology
and Cardiovascular Surgery at Hamad Medical Corporation (HMC)
for collecting and cleaning data for the analysis and thank the Medical
Research Center and its Research Committee at HMC for providing eth-
ical approval of this study. The authors have no disclosures.
REFERENCES
1. Roger VL, Go AS, Lloyd-Jones DM et al.; American Heart As-
sociation Statistics Committee and Stroke Statistics
Subcommittee. Heart disease and stroke statistics--2012 update:
a report from the American Heart Association. Circulation
2012; 125: e2-e220.
2. Piccini JP, Hammill BG, Sinner MF et al. Incidence and preva-
lence of atrial fibrillation and associated mortality among Medicare
beneficiaries, 1993-2007. Circ Cardiovasc Qual Outcomes
2012; 5: 85-93.
3. Benjamin EJ, Levy D, Vaziri SM, D'Agostino RB, Belanger AJ,
Wolf PA. Independent risk factors for atrial fibrillation in a pop-
ulation-based cohort. The Framingham Heart Study. JAMA
1994; 271: 840-4.
4. Salam AM. Managing atrial fibrillation in older people: a com-
parison of two treatment strategies. J Am Geriatr Soc 2003; 51:
1806-7.
5. Miyasaka Y, Barnes ME, Gersh BJ et al. Secular trends in inci-
dence of atrial fibrillation in Olmsted County, Minnesota, 1980 to
2000, and implications on the projections for future prevalence.
Circulation 2006; 114: 119-25.
6. Kurian AK, Cardarelli KM. Racial and ethnic differences in car-
diovascular disease risk factors: a systematic review. Ethn Dis
2007; 17: 143-52.
7. Soliman EZ, Alonso A, Goff DC Jr. Atrial fibrillation and ethnicity:
the known, the unknown and the paradox. Future Cardiol 2009;
5: 547-56.
8. McKee PA, Castelli WP, McNamara PM, Kannel WB. The natural
history of congestive heart failure: the Framingham study. N
Engl J Med 1971; 285: 1441-6.
9. Nomenclature and criteria for diagnosis of ischemic heart disease.
Report of the Joint International Society and Federation of
Cardiology/World Health Organization task force on standard-
ization of clinical nomenclature. Circulation 1979; 59: 607-9.
10. Lam DW, LeRoith D. The worldwide diabetes epidemic. Curr
Opin Endocrinol Diabetes Obes 2012; 19: 93-6.
11. Lopes RD, Pieper KS, Horton JR et al. Short- and long-term out-
comes following atrial fibrillation in patients with acute coro-
nary syndromes with or without ST-segment elevation. Heart
2008; 94: 867-73.
12. Hylek EM, D'Antonio J, Evans-Molina C, Shea C, Henault LE,
Regan S. Translating the results of randomized trials into clinical
practice: the challenge of warfarin candidacy among hospitalized
elderly patients with atrial fibrillation. Stroke 2006; 37: 1075-80.
13. Bungard TJ, Ghali WA, Teo KK, McAlister FA, Tsuyuki RT. Why
do patients with atrial fibrillation not receive warfarin? Arch
Intern Med 2000; 160: 41-6.
14. Go AS, Hylek EM, Borowsky LH, Phillips KA, Selby JV, Singer
DE. Warfarin use among ambulatory patients with nonvalvular atri-
al fibrillation: the anticoagulation and risk factors in atrial fibrillation
(ATRIA) study. Ann Intern Med 1999;131: 927-34.
15. Lackie CL, Garbarino KA, Pruetz JA. Warfarin therapy for atri-
al fibrillation in the elderly. Ann Pharmacother 2002; 36: 200-4.
16. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic
therapy to prevent stroke in patients who have nonvalvular atri-
al fibrillation. Ann Intern Med 2007; 146: 857-67.
17. Mant J, Hobbs FD, Fletcher K et al.; BAFTA investigators;
Midland Research Practices Network (MidReC). Warfarin versus
aspirin for stroke prevention in an elderly community population
with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment
of the Aged Study, BAFTA): a randomised controlled trial.
Lancet 2007; 370: 493-503.
18. SPAF II Investigators. Warfarin versus aspirin for prevention of
Table 5 - Continued.
Author (ref.) Study Year of Number of Major Major conclusions
publication patients population/
ethnicities
studied
Meschia et al. Racial disparities in 2010 432 Caucasians 344, Blacks were less likely than whites to be aware
(34) awareness and treatment African-Americans 88 of having AF or to be treated with warfarin
of AF. The Reasons
for Geographic and
Racial Differences in
Stroke (REGARDS) study
Sun et al. (35) Comparison of frequency 2011 2342 Caucasians 1838, AF was significantly less common among
of AF after coronary artery African-Americans 504 African-American patients than among
bypass grafting in African European-American patients after coronary
Americans vs European artery bypass grafting
Americans
Current study Effect of age on treatment, Current 3848 Asians 548, Elderly patients were more likely to have
trends and outcome of Middle-Eastern hypertension and chronic renal impairment,
patients hospitalized with Arabs 2857 associated coronary artery disease and aortic
atrial fibrillation: insights stenosis in elderly patients with a lower left
from a 20-years registry ventricular ejection fraction than the younger
in a Middle-Eastern country age groups. The older AF patients had
(1991-2010) significantly higher in-hospital mortality and
stroke rates with no significant changes in
mortality trends over the 20 years of study
X: total number of patients; AF: atrial fibrillation.
©2012, Editrice Kurtis
FOR PERSONAL USE ONLY
A.M. Salam, H.A. AlBinali, E.M. Al-Sulaiti et al.
690 Aging Clin Exp Res, Vol. 24, No. 6
thromboembolism in atrial fibrillation: Stroke Prevention in Atrial
Fibrillation II Study. Lancet 1994; 343: 687-91.
19. Yamaguchi T. Optimal intensity of warfarin therapy for sec-
ondary prevention of stroke in patients with nonvalvular atrial fib-
rillation : a multicenter, prospective, randomized trial. Japanese
Nonvalvular Atrial Fibrillation-Embolism Secondary Prevention
Cooperative Study Group. Stroke 2000; 31: 817-21.
20. Pengo V, Cucchini U, Denas G et al. Lower versus standard in-
tensity oral anticoagulant therapy (OAT) in elderly warfarin-ex-
perienced patients with non-valvular atrial fibrillation. Thromb
Haemost 2010;103: 442-9.
21. Castelino RL, Chen TF, Guddattu V, Bajorek BV. Use of evi-
dence-based therapy for the prevention of cardiovascular events
among older people. Eval Health Prof 2010; 33: 276-301.
22. Winkelmayer WC, Fischer MA, Schneeweiss S, Wang PS, Levin
R, Avorn J. Underuse of ACE inhibitors and angiotensin II re-
ceptor blockers in elderly patients with diabetes. Am J Kidney Dis
2005; 46: 1080-7.
23. Pappoe LS, Winkelmayer WC. ACE inhibitor and angiotensin II
type 1 receptor antagonist therapies in elderly patients with diabetes
mellitus: are they underutilized? Drugs Aging 2010; 27: 87-94.
24. Miyasaka Y, Barnes ME, Bailey KR et al. Mortality trends in pa-
tients diagnosed with first atrial fibrillation: a 21-year communi-
ty-based study. J Am Coll Cardiol 2007; 49: 986-92.
25. Bilato C, Corti MC, Baggio G et al. Prevalence, functional impact,
and mortality of atrial fibrillation in an older Italian population
(from the Pro.V.A. study). Am J Cardiol 2009; 104: 1092-7.
26. Furberg CD, Psaty BM, Manolio TA, Gardin JM, Smith VE,
Rautaharju PM. Prevalence of atrial fibrillation in elderly subjects
(the Cardiovascular Health Study). Am J Cardiol 1994; 74:
236-41.
27. Lake FR, Cullen KJ, de Klerk NH, McCall MG, Rosman DL.
Atrial fibrillation and mortality in an elderly population. Aust N Z
J Med 1989; 19: 321-6.
28. Go AS, Hylek EM, Phillips KA et al. Prevalence of diagnosed atri-
al fibrillation in adults: national implications for rhythm man-
agement and stroke prevention: the AnTicoagulation and Risk
Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001; 285:
2370-5.
29. Ruo B, Capra AM, Jensvold NG, Go AS. Racial variation in the
prevalence of atrial fibrillation among patients with heart failure:
the Epidemiology, Practice, Outcomes, and Costs of Heart
Failure (EPOCH) study. J Am Coll Cardiol 2004; 43: 429-35.
30. Dang D, Patel R, Haywood LJ. Atrial fibrillation in a multiethnic
inpatient population of a large public hospital. J Natl Med Assoc
2004; 96: 1438-44.
31. Bush D, Martin LW, Leman R, Chandler M, Haywood LJ; NHLBI
AFFIRM Investigators. Atrial fibrillation among African Americans,
Hispanics and Caucasians: clinical features and outcomes from
the AFFIRM trial. J Natl Med Assoc 2006; 98: 330-9.
32. Novaro GM, Asher CR, Bhatt DL et al. Meta-analysis compar-
ing reported frequency of atrial fibrillation after acute coronary
syndromes in Asians versus whites. Am J Cardiol 2008; 101,
506-9.
33. Shen AY, Contreras R, Sobnosky S et al. Racial/ethnic differences
in the prevalence of atrial fibrillation among older adults--a cross-
sectional study. J Natl Med Assoc 2010; 102: 906-13.
34. Meschia JF, Merrill P, Soliman EZ et al. Racial disparities in aware-
ness and treatment of atrial fibrillation: the REasons for
Geographic and Racial Differences in Stroke (REGARDS) study.
Stroke 2010; 41: 581-7.
35. Sun X, Hill PC, Lowery R et al. Comparison of frequency of atri-
al fibrillation after coronary artery bypass grafting in African
Americans versus European Americans. Am J Cardiol 2011; 108:
669-72.
©2012, Editrice Kurtis
FOR PERSONAL USE ONLY
