Atrial fibrillation in long term care

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.