Catheter ablation for atrial fibrillation is associated with reduced risk of mortality in the elderly:a prospective cohort study and propensity score analysis

Background It is unclear whether catheter ablation(CA)for atrial fibrillation(AF)affects the long-term prognosis in the elderly.This study aims to evaluate the relationship between CA and long-term outcomes in elderly patients with AF.Methods Patients more than 75 years old with non-valvular AF were prospectively enrolled between August 2011 and December 2017 in the Chinese Atrial Fibrillation Registry Study.Participants who underwent CA at baseline were propensity score matched(1:1)with those who did not receive CA.The outcome events included all-cause mortality,cardiovascular mortality,stroke/transient ischemic attack(TIA),and cardiovascular hospitalization.Results Overall,this cohort included 571 ablated patients and 571 non-ablated patients with similar characteristics on 18 dimensions.During a mean follow-up of 39.75±19.98 months(minimum six months),24 patients died in the ablation group,compared with 60 deaths in the non-ablation group[hazard ratio(HR)=0.49,95%confidence interval(CI):0.30-0.79,P=0.0024].Besides,6 ablated and 29 non-ablated subjects died of cardiovascular disease(HR=0.25,95%CI:0.11-0.61,P=0.0022).A total of 27 ablated and 40 non-ablated patients suffered stroke/TIA(HR=0.79,95%CI:0.48-1.28,P=0.3431).In addition,140 ablated and 194 non-ablated participants suffered cardiovascular hospitalization(HR=0.84,95%CI:0.67-1.04,P=0.1084).Subgroup analyses according to gender,type of AF,time since onset of AF,and anticoagulants exposure in initiation did not show significant heterogeneity.Conclusions In elderly patients with AF,CA may be associated with a lower incidence of all-cause and cardiovascular mortality.

Atrial fibrillation in the elderly: Is ablation ready for prime time ?

Atrial fibrillation is the most common sustained arrhythmia and results in significant morbidity, especially in the elderly. The prevalence of atrial fibrillation increases dramatically with advancing age to almost 6% in individuals older than 65 years. In fact, 84% of people with atrial fibrillation are over 65 years of age.1 Additionally, the risk of stroke increases with advancing age, such that one-third of strokes in patients over the age of 65 are caused by atrial fibrillation.

Atrial fibrillation in the elderly

Atrial fibrillation(AF)is the most common arrhythmia in elderly population,with age being one of the most important factors involved in its pathogenesis.Conduction disturbances may be present on the surface electrocardiogram before AF onset in some patients.Once this arrhythmia is diagnosed,antithrombotic therapy is mandatory in most cases,as this is the only treatment that has demonstrated to improve survival.Age increases both the risk of thromboembolic and bleeding complications,while benefits from anticoagulant therapy outweigh that from bleeding in most scenarios,also in very elderly patients.However,elderly patients with AF are often undertreated.Non-vitamin K antagonist oral anticoagulants have emerged as an alternative to vitamin K antagonists,with significant less adverse events and better profile in terms of efficacy and safety.Other conditions related to age should be carefully evaluated in these patients(including frailty,comorbidity and polypharmacy)to ensure an individualized clinical and therapeutic approach.

Atrial fibrillation in the elderly

Atrial fibrillation (AF) is an extremely common condition in the elderly, with increasing prevalence around the world as the population ages. AF may be associated with serious health consequences, including stroke, heart failure, and decreased quality of life, so that careful management of AF by geriatric health care providers is required. With careful attention to anticoagulation therapy, and prudent use of medications and invasive procedures to minimize symptoms, many of the adverse health consequences of AF can be prevented.

Clinical Characteristics and Risk Factors of Atrial Fibrillation in the Elderly

Objective: To investigate the epidemiobgical characteristics of the elderly with atrial fibrillation (AF) in age, gender, the types of AF and relative causes. And To analyze the risk factors of persistent AF (PeAF), then use them to guide to prevent and treat for AF in the elderly.Methods: Collect the data of elderly patients with AF who were admitted to Liaoning People's Hospital from September 1, 2016 to September 30, 2017, and summarize the epidemiological characteristics of AF in the elderly. The risk factors for PeAF were analyzed by Spearman correlation analysis and mltivariate logistic regression analysis. Result: 1. In the elderly, the number of AF cases increase with age. The group of 75-84 years old was the largest part. The number of older females was larger than male in all ages. It was important to pay more attention to old woman with AF. 2.In the elderly, nonvalvular atrial fibrillation is popular. The top three causes of AF in the elderly were CHD, hypertension and heart failure. In the elderly, comorbidities were frequent, and the management was a major therapeutic objective. 3.CRP, 1eft atria diameter were the independent risk factors for PeAF in the elderly.

Is dual therapy the correct strategy in frail elderly patients with atrial fibrillation and acute coronary syndrome?

Atrial fibrillation(AF)is a very common arrhythmia in clinical practice.Its incidence and prevalence are age-related and are growing in the last years.Age is a risk factor also for coronary artery disease(CAD),and with the evolution of preventive care,the first event(acute coronary syndrome(ACS)or percutaneous coronary intervention(PCI))takes place at a later age.If elderly patients with AF and CAD undergo ACS or PCI,they have indication to assume triple therapy.Triple therapy(oral anticoagulation(OAC)plus dual antiplatelet therapy(DAPT))exposes patients to high bleeding risk.In the last 10 years,several clinical trials have tested dual therapy(OAC plus single antiplatelet therapy)in AF patients who undergo ACS or elective PCI.WOEST trial has tested warfarin+clopidogrel against triple therapy.PIONEER AF-PCI trial has tested low-dose rivaroxaban+P2Y12 inhibitor or very low-dose rivaroxaban+DAPT against standard triple therapy with warfarin.RE-DUAL PCI trial has tested two doses of dabigatran+P2Y12 inhibitor against standard triple therapy with Warfarin.AUGUSTUS trial has tested apixaban against warfarin both in dual therapy with P2Y12 inhibitor and in triple therapy with a P2Y12 inhibitor and aspirin.ENTRUST-AF PCI,last published study,has tested edoxaban+P2Y12 inhibitor against triple therapy.All these trials show dual therapy reduces significantly bleeding risk than triple therapy.In this paper,we analyze these clinical trials to understand if dual therapy results can be applied to elderly patients and what is probably the better approach in elderly AF patients undergo to ACS or PCI.

Catheter ablation of atrial fibrillation in elderly population

Background Although elderly patients have been included in published series of catheter ablation for atrial fibrillation （AF）, clinicalbenefit and safety remain still less defined in this population. A retrospective analysis of the results of catheter ablation for AF in a large volumecenter focused on comparison of elderly patients with the rest of the patient cohort was conducted in this study. Methods Consecutive patientswho underwent catheter ablation for AF between January 2001 and December 2016 were analysed. A total population of 3197 patients wasdichotomized by the age of 70 years （394 elderly vs. 2803 younger subjects）. Patients were followed in terms of arrhythmia status and sur-vival for a median period of 18 vs. 21 and 35 vs. 57 months, respectively. Results Elderly patients were more frequently females （49% vs.29%, P 〈 0.0001）, had a history of hypertension （79% vs. 57%, P 〈 0.0001）, diabetes （16% vs. 11%, P 〈 0.01）, stroke （9% vs. 6%, P 〈 0.01）,coronary/peripheral artery disease （14% vs. 8%, P 〈 0.0001）, and CHAzDS2-VASc score （3.1 ± 1.3 vs. 1.5 ± 1.2 s, P 〈 0.0001）. Major com-plications were more frequent in elderly （5.3% vs. 3.2%, P = 0.03）; however, this difference was driven by vascular complications （3.6% vs.1.9%, P = 0.04）. There were comparable rates of cerebrovascular （0.3 vs. 0.3%） or nonvascular complications （1.8 vs. 1.2%）. Good arrhyth-mia control was inferior in elderly patients as compared with the rest of the cohort, both without and with antiarrhythmic drugs： 44.2% vs.58.2% （P 〈 0.0001） and 78.2 vs. 83.2% （P 〈 0.01）, respectively. Poor arrhythmia control was associated with relative risk of all-cause mor-tality of 2.7 （95% CI： 1.1-6.4） in elderly patients and 1.4 （95% CI： 0.9-2.0） in younger subjects. Conclusions Catheter ablation for AF inelderly patients is safe although somewhat less effective. Good arrhythmia control is associated with better survival, especially in elderly patients.

Analyses of risk factors and prognosis for new-onset atrial fibrillation in elderly patients after dual-chamber pacemaker implantation

Objective To retrospectively identify risk factors and the prognosis for new-onset atrial fibrillation (AF)after implantation of dual-chamber pacemakers in elderly patients.Methods Consecutive patients aged >65years who underwent their first implantation of a dual-chamber permanent pacemaker in Beijing Anzhen Hospital from October 2013to May 2016were enrolled.Their complete program- ming and follow-up data were recorded.Follow-up end points included new-onset AF and major adverse cardiovascular and cerebrovascular events.Restdts Altogether,322patients were enrolled,with new-onset AF observed in 79(24.5%)during their follow-up.Multivariable analysis identified four independent predictors of new-onset AF in elderly patients after pacemaker implantation:hypertension (HR =3.040, 95%CI:1.09-3.05,P =0.00),age (HR =1.966,95%CI:1.57-3.68,P =0.01);left atrial enlargement (HR =1.645,95%CI:1.05-1.25,P = 0.03);high ventricular pacing rate (HR =1.137,95%CI:1.01-1.06,P =0.01).Univariable analysis indicated that the CHA2DS2-VASc score was also a risk factor for AF (HR =1.368,95%CI:1.178-1.589,P =0.002),whereas multivariable regression analysis did not. Kaplan-Meier survival analysis showed that the risk for ischemic stroke was significantly higher in the new-onset AF group than in the non-AF group (P <0.05).Conclusion Hypertension,age,left atrial enlargement,and high ventricular pacing rate were independent predictors of new-onset AF in elderly patients after implantation of a permanent pacemaker.New-onset AF increased the risk for ischemic stroke.

Percutaneous interventions in elderly patients with atrial fibrillation： leftatrial ablation and left atrial appendage occlusion

Heart rhythm disturbances become of special importancewhen patients reach a senior age. Atrial fibrillation （AF） isthe most prevalent arrhythmia among the old age groups,and its impact on morbidity and mortality becomes of para-mount significance. In this population, AF is responsible forsignificant amount of thromboembolic cerebrovascularevents, especially for disabling and fatal strokes, Follow-ing announcement of the special issue of the Journal of Geri-atric Cardiology devoted to heart rhythm disorders in theelderly, a number of submissions have been received withAF as the major topic of authors＇ researches.

Hyperuricemia predicted adverse outcomes in very elderly patients with non-valvular atrial fibrillation

Objective Elevated serum uric acid predicts poor outcomes in patients with cardiovascular disease.We aimed to examine associations between hyperuricemia and clinical outcomes among very elderly patients with non-valvular atrial fibrillation(NVAF).Methods Elderly patients(≥80 years)with NVAF admitted to our hospital from January 2009 to December 2015 were retrospectively studied and were followed up until April 2017.

Pulse Pressure as a Risk Factor of Atrial Fibrillation in Black African Elderly Patients

Objective: The aim of this study was to show the prognostic role of High Pulse Pressure (PP) in the occurrence of atrial fibrillation in Black African elderly patients. Materials and Methods: In a comparative retrospective study related to 2000 patients admitted to the Institute of Cardiology of Abidjan, from January 1991 to December 2010 for atrial fibrillation, we matched pulse pressure and atrial fibrillation in Black African elderly patients. Results: The mean age of patients was 65 ± 10 years. Patients with high pulse pressure were 4.8 times more at risk to present atrial fibrillation than those with normal pulse pressure. The threshold of high risk pulse pressure was 65 mmHg. Conclusion: Pulse pressure is a factor of bad prognosis of atrial fibrillation in Black African elderly patients.

Analysis of the Impact Factors on a Stable Warfarin Dose in Extreme Elderly (Age ≥ 80 Years) Chinese Patients with Non-Valvular Atrial Fibrillation

Purpose: The aim of this study was to investigate non-genetic and genetic factors contributing to stable warfarin dose change in the extreme elderly patients with non-valvular atrial fibrillation. Methods: A total of 40 elderly patients with stable warfarin doses were included in this study. Clinical basic data, such as age, sex, body mass index, basic disease like hypertension, diabetes and coronary heart disease had been recorded. Two nucleotide polymorphisms about VKORC1-1639G^A and CYP2C9 1075A^C genes were detected via sequencing by hybridization. Results: The elderly patients with CYP2C9 1075A^C (CA) genotype needed less warfarin daily doses than those?with CYP2C9 1075A^C (AA) genotype (1.93 ± 0.79 mg/d VS 2.15 ± 0.64 mg/d), but there was no significant difference (p = 0.601). While the daily warfarin dose required for patients with VKORC1-1639G^A (AA) genotype was significantly lower than that for patients with VKORC1-1639G^A (GA) genotype (2.00 ± 0.67 mg/d VS 2.63 ± 0.38 mg/d, p = 0.012). VKORC1-1639G^A together with age and diabetes status accounted 41.7% for dose variability. The new algorithm was developed using multivariate linear regression analysis;the model was developed for: Dose = 7.731 – 0.056 * age + 0.527 * DM - 0.785 * VKORC1. Conclusions: VKORC1-1639G^A together with age and diabetes status might predict warfarin doses in age ≥ 80 years patients with non-valvularatrial fibrillation. In contrast, the polymorphism of CYP2C9 1075A^C was not associated with dose variability.

Clinical outcomes of radiofrequency catheter ablation of atrial fibrillation in octogenarians lO-year experience of a one high-volume center

Background Prevalence of atrial fibrillation （AF） increases with age. Radiofrequency catheter ablation （RFCA） is an establishedtreatment option superior to antiarrhythmics （AAs）. In this study, we investigated safety and efficacy of RFCA of AF in octogenarians.Methods From our database, we extracted procedural and follow-up data for patients 〉 80 years with symptomatic AF undergoing RFCAand compared this population to RFCA patients 〈 50 years. All patients underwent pulmonary vein isolation （PVI） supplemented by linearlesions in PVI-nonresponders. Arrhythmia-free survival was assessed using seven day Holter every three months post procedure. All patientscompleted their 12 months follow-up. Results Fifty patients aged ≥80 years （80.5 ± 1.6 years） were compared to 259 patients aged 〈 50years （43.5±5.5 years）. The RFCA complication rate did not vary between groups. No differences in procedural characteristics were seenafter being analyzed by type of AF. Among patients with paroxysmal AF, 71.4% octogenarian vs. 84.7% young patients was free of anyarrhythmia, without AAs, after single procedure. For non-paroxysmal AF, arrhythmia-free survival without AAs, was considerably lower（58.6% octogenarians vs. 81.2% younger patients, P = 0.023）. If AAs were used, arrhythmia-free survival for paroxysmal AF increased to90.5% and 92.1% in octogenarians and younger patients, respectively; and in non-paroxysmal AF it increased to 79.3% vs. 88.4%. ConclusionsRFCA is a safe and effective strategy to achieve normal sinus rhythm in a highly selected group of octogenarians. Paroxysmal AF ablation inoctogenarians has similar clinical effectiveness as that seen in much younger patients. Non-paroxysmal AF ablation has lower, but still rea-sonable clinical effectiveness.

Comparison of long-term outcome between patients aged 〈 65 years vs. ≥ 65 years after atrial fibrillation ablation

Background Atrial fibrillation （AF） is the most frequent arrhythmia, and its prevalence is increasing with aging. We aimed to com-pare the long-term outcome data of patients 〈 65 years vs.≥ 65 years who underwent catheter ablation （CA） for drug-refractory AF. MethodsConsecutive patients with primary pulmonary vein isolation performed between March 2001 and December 2011, and those who completeda five-year of follow-up were divided into two groups： patients aged 〈 65 years into group 1, and patients aged ≥ 65 into group 2. Long-termoutcome data concerning mortality, thromboembolic events （TE） and success rates were compared between these groups. Results A totalnumber of 390 patients were included, group 1 contained 310 patients, and 80 patients in group 2. In group 2, patients had more often impairedrenal function （P 〈 0.001） and thyroid disease （P = 0.047）. A total of fifteen patients died during the 6.63 ± 2.1 years of follow-up, with a sig-nificantly higher incidence in the older group （8/80 vs. 7/310 patients, P = 0.004）. The majority of fatal outcome was due to cancerous dis-eases in both groups. No difference was observed concerning the long-term TE rate （12/310 vs. 4/80 patients, P = 0.75）. Rhythm controlfailed in 25.9% of the patients, with no difference between the groups： 26.4% in group 1 vs. 23.7% in group 2 （P = 0,67）, ConclusionsDespite growing prevalence of AF in aging population, the elderly patients are underrepresented in CA procedures. Similar clinical successand TE complication rate are observed between the age-groups. Our data suggest more liberal criteria might be applied while selecting pa-tients for AF ablation.

Opportunistic screening for atrial fibrillation with a single lead device in geriatric patients

Objective To determine the diagnostic yield of repeated screening for atrial fibrillation(AF)among geriatric patients.Methods A pragmatic prospective cohort study into applying opportunistic screening for AF with a handheld single lead ECG device(SLD)in a geriatric cohort.Consecutive patients of 65 years old and older visiting the geriatric outpatient clinic were eligible for inclusion.A 12 lead ECG was performed,followed by measurements with the SLD during every visit to the geriatric outpatient clinic.A frailty index was based on the accumulation of deficits model.Results 478 patients were eligible.Patients were excluded if they did not give informed consent(17 patients),had a pacemaker or implantable cardioverter defibrillator(20 patients),or had incomplete medical files(two patients).After exclusion,439 patients participated in this study.The mean age was 78 years(range 65 to 100 years),54%were female.AF was known in 89 patients(20%),first detected on the baseline ECG in four patients(1%)and first detected with the SLD in 20 patients(5%)during follow up visits.Sensitivity of the SLD was 90.0%,specificity 99.0%,negative predictive value 99.7%,and positive predictive value 73.5%.Most patients(82%)with AF were frail and 53%were severely frail.Conclusion Repeated screening in geriatric patients has a five times higher diagnostic yield than usual care.It was easily combined with usual care.Because of the positive predictive value of 73.5%,it remains necessary to confirm AF with a 12 lead ECG or 24-h Holter monitoring.

Prevalence and Risk Factors of Atrial Fibrillation in Chinese Elderly： Results from the Chinese Longitudinal Healthy Longevity Survey

Background： Prevalence of atrial fibrillation （AF） is increasing as the world ages. AF is associated with higher risk of mortality and disease, including stroke, hypertension, heart failure, and dementia. Prevalence of AF differs with each population studied, and research on non-Western populations and the oldest old is scarce. Methods： We used data from the 2012 wave of the Chinese Longitudinal Healthy Longevity Survey, a community-based study in eight longevity areas in China, to estimate AF prevalence in an elderly Chinese population （n = 1418, mean age = 85.6 years） and to identify risk factors. We determined the presence olAF in our participants using single-lead electrocardiograms. The weighted prevalence olAF was estimated in subjects stratified according to age groups （65-74, 75 84, 85-94, 95 years and above） and gender. We used logistic regressions to determine the potential risk factors of AF. Results： The overall prevalence of AF was 3.5%; 2.4% of men and 4.5% of women had AF （P 〈 0.05）. AF was associated with weight extremes of being underweight or overweight/obese. Finally, advanced age （85 94 years）, history of stroke or heart disease, low high-density lipoprotein levels, low triglyceride levels, and lack of regular physical activity were associated with AF. Conclusions： In urban elderly AF prevalence increased with age （P 〈 0.05）, and in rural elderly, women had higher AF prevalence （P 〈 0.05）. Further exploration of population-specific risk factors is needed to address the AF epidemic.

Clinical profile and outcomes of atrial fibrillation in elderly patients with acute myocardial infarction

Background Atrial fibrillation （AF） occurs commonly in patients with acute myocardial infarction （MI） and is associated with an increased long-term mortality. This study aimed to investigate the clinical characteristics and outcomes of AF in in-hospital elderly Chinese patients with acute MI. Methods A total of 967 patients with acute MI, aged 〉65 years, were categorized on the basis of the absence or presence of AF. Patients with documented AF were classified into two subgroups： the ongoing AF group and the new-onset AF group. We retrospectively evaluated the clinical profile, in-hospital outcomes, and effects of revascularization on the incidence of AF in elderly patients with acute MI. Results AF was documented in 100 （11.53%） patients and the incidence of new-onset AF was 6.51% during hospitalization. History of old MI and cerebrovascular events were more common in patients with AF than in those without AF （P 〈0.001, P 〈0.01, respectively）. The incidence of AF was higher in patients with non-ST elevated MI （P=0.014）, inferior wall MI （P=0.004） and cardiac function of Killip class Ⅲ or Ⅳ （P=-0.008）. Patients with AF had more complication of pneumonia （P=0.003） and longer hospital stay. Left circumflex coronary artery involvement was more common in patients with AF （compared with patients without AF, P 〈0.001）. Percutaneous coronary intervention or coronary artery bypass grafting significantly decreased the incidence of new-onset AF from 7.97% to 3.82% （P=0.017）. AF depended to heart failure, increased the in-hospital mortality. Conclusions AF is common in elderly patients with acute MI and is associated with poorer clinical outcomes. Revascularization reduces the incidence of AF and thus improves the clinical outcomes in these patients.

Embolic events in 93 elderly Chinese patients with atrial fibrillation

To evaluate the prevalence of embolic events and relevant factors in elderly Chinese patients with atrial fibrillation(AF), and to provide evidence on ways to prevent embolic events Methods Autopsy data from ninety three continous elderly Chinese patients with AF were analysed The incidence of embolic events and its relationship to underlying disease, pathologic changes in the heart, and other clinical characteristics were examined Results Embolism were observed in 27 of 93 cases, with an incidence of 29 03% The incidence of embolic events was higher in elderly patients with rheumatic heart disease than those with coronary artery disease, hypertensive myocardiopathy and heart diseases Patients with chronic AF,with a course of AF≥3 years, and those with heart failure or diabetes had a higher incidence of embolic events than those without these complications There was significant difference in incidence between paroxysmal and chronic AF Patients with left atrial or ventricular enlargement, mural thrombosis in cardiac chambers, valvular calcification and valvular vegetation also had a higher incidence of embolic events Oral dipyridamole (75-150?mg/d) or aspirin (50-150?mg/d) showed no definite effects in preventing embolism in some patients Conclusions There was a high incidence of embolic events in elderly Chinese patients with AF Anticoagulation therapy should be provided to the elderly patients with AF, especially to the patients with risk factors for embolism

Insight into appropriate medication prescribing for elderly in the COVID-19 era

Coronavirus disease 2019(COVID-19)complicates clinical management in elderly population.There is an additional need to properly treat and monitor elderly COVID-19 patients.This paper discusses the inappropriate medication prescribing in the elderly and suggests an updated valid assessment tool considering COVID-19 and its treatment.

Prevalence and risk factors of atrial fibrillation in preterminal inpatients aged 60 years and over

Background Atrial fibrillation is a common arrhythmia and a major risk factor for ischaemic stroke. We investigated the prevalence of atrial fibrillation and its relation to age, gender and underlying heart disease in patients aged 60 years and over who died during hospitalization.Methods Between 1955 and 2005, 1519 autopsies of in-hospital deaths in Beijing Hospital were performed. Among them, 540 cases met criteria of age ≥60 years and full clinical history including electrocardiogram, echocardiogram, myocardial perfusion images and detailed cardiac pathology records from autopsy.Results Atrial fibrillation occurred in 193 of 540 patients and prevalence increased with age （10.5% in patients younger than 60 years, 39.6% （80-89 years） and 54.8% （≥ 90 years）） being higher in patients with underlying heart disease than without heart disease （P 〈0.0001）. Coronary artery disease （CAD）, congestive heart failure, cardiac valve dysfunction and chronic renal failure were associated with a higher prevalence of atrial fibrillation （P 〈0.001）. CAD with anterior myocardial infarction or left anterior descending artery disease was also associated with an increased prevalence of atrial fibrillation （P 〈0.05）. Following autopsy, clinical misdiagnosis of CAD increased with age and missed clinical diagnosis of CAD decreased with age. Multivariate Logistic regression analysis revealed independent predictors of atrial fibrillation： age （OR=1.335, 95% CI： 1.114-1.600, P 〈0.0001）, underlying heart disease （OR=2.019, 95% CI： 1.244-3.278, P 〈0.005）, chronic heart failure （OR=1.873, 95% CI： 1.272-2.757, P 〈0.005）, mitral regurgitation （OR=2.163, 95% CI： 1.093-4.278, P 〈0.05） and mitral stenosis （OR=33.575, 95% CI： 2.852-395.357, P 〈0.05）.Conclusions A high prevalence of atrial fibrillation was found in Chinese patients ≥60 years who died in hospital, especially when associated with underlying heart disease. The independent risk factors of atrial fibrillation were age, underlying heart disease, congestive heart failure and mitral valve dysfunction. High clinical misdiagnosis and missed diagnosis of CAD were associated with age.