Underutilization of Warfarin Therapy in Elderly Patients with Atrial Fibrillation – Fear or False Sense of Security!

Background: Under utilization of warfarin in elderly patients with atrial fibrillation (AF) has been recognized as a significant health care issue. This study examines the rate and reasons for warfarin underutilization in elderly patients with AF at the Kansas City Veterans Affairs Medical Center.

Methods: Retrospective study reviewing electronic medical records of all patients aged 65 and older with the diagnosis of atrial fibrillation. Patients on warfarin were excluded. Reasons for not using warfarin were extracted by reviewing the electronic medical record. Anticoagulation indications for these patients were determined based on the ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation.

Results:Warfarin was not used by 407 patients (25%) with known AF. Average age was 79+6.2 years. 60% of patients had persistent or permanent AF. Prevalence of risk factors for thromboembolism included hypertension (74%), heart failure or ejection fraction of <40%

Conclusions:Underutilization of warfarin in elderly patients with atrial fibrillation remains a common problem despite their high risk for thromboembolic events. A false sense of security about the paroxysmal nature of AF, lack of proper insight about stroke risk (CHADS (2)), and fear of bleeding are the most common reasons for non use of warfarin.

Patient Perspective :Echocardiographic Prediction of Symptomatic Atrial Fibrillation In Patients with Rheumatic Mitral Stenosis and Normal Sinus Rhyth

Citation : Fahriye Vatansever Agca, Ozan Kinay, Mustafa Karaca,Muge Ildizli Demirbas,Serdar Biceroglu,Baris Kilicarslan,Cem Nazli,A. Oktay Ergene.Echocardiographic Prediction of Symptomatic Atrial Fibrillation In Patients with Rheumatic Mitral Stenosis and Normal Sinus Rhythm. JAFIB .2008 Sep;1(3): 139-144.

Mitral stenosis is a valvular heart disease characterized by the narrowing of the orifice of the mitral valve of the heart.Rheumatic mitral stenosis (RMS) increases the risk of both atrial fibrillation (AF) and thromboembolism.

Dr. Karaca et al from Atakalp Heart Hospital Cardiology Department,Turkey report the benefit of echocardiography to predict symptomatic AF in a study on patients with mitral stenosis and normal sinus rhythm.

Echocardiographic Prediction of Symptomatic Atrial Fibrillation In Patients with Rheumatic Mitral Stenosis and Normal Sinus Rhythm

Objectives: Rheumatic mitral stenosis (RMS) increases the risk of both atrial fibrillation (AF) and thromboembolism. 

Methods: Patients with mitral stenosis and normal sinus rhythm were enrolled in the study prospectively.The present study was designed to study whether echocardiographic evaluation in patients with mitral stenosis and normal sinus rhythm could predict the occurrence of symptomatic AF . 

Results: Sixty-two patients (51 females) with mitral stenosis and normal sinus rhythm were included in the study. Seven patients (11.2%) developed symptomatic AF and the remaining 55 were free of AF during a followed-up of 22±5 months. The following echocardiographic parameters were significantly increased and predicted the development of AF: left atrial(LA) mediolateral diameter (5.5 ± 0.5 cm vs 4.7 ± 0.7 cm), right atrial mediolateral diameter (4,7 ± 1.0 cm vs 3.6 ± 1.3 cm), LA area in the apical two chamber view ( 31 ± 3.2 cm2 vs 25 ± 5.8 cm2), right atrial volume (52 ± 22 cm3 vs 34 ± 19 cm3), and interatrial conduction time (IACT) (132 ± 22 msec vs 115 ± 16 msec). 

Conclusions: This study revealed that echocardiography can be used to predict symptomatic AF in patients with RMS and sinus rhythm.

Patient Perspective : Atrial Septal Defect and Atrial Fibrillation

Citation : George E. Blake, Dhanunjaya Lakkireddy. Atrial Septal Defect and Atrial Fibrillation. JAFIB .2008 Sep;1(3):173-184.


Atrial septal defect (ASD) is a form of congenital heart defect that enables blood flow between the left and right atria via the interatrial septum. The interatrial septum is the tissue that divides the right and left atria. Without this septum, or if there is a defect in this septum, it is possible for blood to travel from the left side of the heart to the right side of the heart, or vice versa.

Atrial Fibrillation (AF) is a common complication of ASD, and Dr. Blake et al from University of Kansas, Kansas City, KS discuss the diagnosis and management of ASD and AF.

Atrial Septal Defect and Atrial Fibrillation

Atrial fibrillation (AF) is a common complication in patients with atrial septal defects (ASDs). The link between AF and ASD is fairly complex and entails modifications in electrophysiologic, contractile and structural properties, at the cellular and tissue level, of both atria, mainly due to chronic atrial stretch and dilation. Surgical repair or transcatheter closure of ASDs are equally effective in reducing mortality and symptoms but limited in preventing or curbing AF, unless combined with an arrhythmia-specific procedure. Transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) have improved the safety and success of the above procedures. Finally, clearer understanding of the pathophysiology of AF in patients with ASD (and CHF, in general) has led to target-specific advances in medical management.

Patient Perspective :Impact of Smoking on the Atrial Substrate Characteristics in Patients with Atrial Fibrillation

Citation : Ta-Chuan Tuan,Shih-Lin Chang, Shih-Ann Chen.Impact of Smoking on the Atrial Substrate Characteristics in Patients with Atrial Fibrillation .JAFIB.2008 Sep;1(3): 170-172.

Smoking has multiple adverse effects on health and is known to be linked to Atrial fibrillation. In a brief review Dr. Steven-Chen et al from Taipei Veterans General Hospital discuss the effects of smoking on the causation, progression and management of Atrial fibrillation.

Impact of Smoking on the Atrial Substrate Characteristics in Patients with Atrial Fibrillation

Cigarette smoking is a common health issue throughout the world. It can cause the development of various major diseases, such as chronic obstructive pulmonary disease (COPD), most cardiovascular diseases and many types of cancer. Thus, people with a tobacco habit can produce devastating health consequences for themselves. At present, there are about five million people that die annually, which can be attributed to cigarette smoking, and half of those deaths, which are mortalities from smoking, always occur in middle age. Therefore, how to reduce cigarette smoking remains the most important work to avoid the causes of health disabilities and premature death.