Management of Arrhythmias in Older Adult Patients ≥75 Years Old Compared to Younger Patients <75 Years Old: Is Contemporary Practice Reflective of Evidence?

The burden of arrhythmias, like most cardiovascular diseases, increases with age, and risks of arrhythmias-associated adverse outcomes, including all-cause mortality, are greater in older adult patients compared with younger patients. Older adult patients (≥75 years old) and patients with cognitive impairment tend to be either significantly underrepresented or systematically excluded from major randomized controlled trials of invasive arrhythmia management. In key arrhythmia clinical trials, the average age of participants has been principally in the 60s, except for studies of oral anticoagulation in atrial fibrillation/flutter, where older adult patients were adequately recruited. Therapies emanating from the findings of these clinical trials, deduced from predominantly younger patients, tend to be speculatively applied to older adult patients, most often with scant or without randomized controlled trial evidence in these patients. While observational studies have provided some reassuring evidence of the usefulness of certain arrhythmia management strategies in older adults, these are often associated with increased risk of adverse outcomes compared with younger patients. These deleterious outcomes have been observed to be more marked in older adult patients with premature biological aging (characterized by increased frailty or high comorbidity burden or other measures). Therefore, uncertainty remains about the benefits and risks of some invasive arrhythmia management in elderhood. This narrative review critically summarizes the current evidence surrounding the efficacy and safety of arrhythmia management in older adult patients ≥75 years old compared with those younger patients <75 years old. It also identifies any significant discrepancies in arrhythmia treatment patterns between the older and younger population and their outcomes.