Heart Rhythm Society (HRS): Heart Rhythm 2011

SAN FRANCISCO – Declaring a patient ‘cured’ of atrial fibrillation on the basis of a lack of symptoms following atrial fibrillation ablation is definitely jumping the gun, the DISCERN AF study indicates.

Implantable loop recorders used in DISCERN AF (Discerning the Incidence of Symptomatic and Asymptomatic Episodes Post Radiofrequency Ablation of AF) clearly documented that the proportion of AF episodes that are asymptomatic markedly increases after ablation, Dr. Atul Verma reported at the annual meeting of the Heart Rhythm Society.

"There is something about the postablation state that is making patients less able to detect their arrhythmia," observed Dr. Verma, DISCERN AF principal investigator and an electrophysiologist at Southlake Regional Health Center in Newmarket, Ont.

DISCERN AF was an eight-center, prospective Canadian study in which 50 patients with symptomatic AF received a Medtronic Reveal XT insertable cardiac monitor at least 3 months before they underwent a standard first-time AF ablation procedure. Eighty percent of participants had paroxysmal AF. The subjects’ mean left atrial size was 41 mm. Dr. Verma presented the study results through 18 months of postablation follow-up, but there will be a subsequent report, because the devices will be left in place for a total of 30 months post ablation.

Patients kept a detailed standardized diary to record the exact times of onset and end of their arrhythmic symptoms. Every 3 months the implantable loop recorder data were downloaded, and all recorded episodes were blindly adjudicated and compared to entries in the symptom diaries.

Radiofrequency ablation (RF) effectively reduced total AF burden. Indeed, the total AF/atrial flutter burden decreased from a mean of 2 hours per day per patient preablation to 0.3 hours per day per patient post ablation, an 86% reduction. But while 52% of all AF/flutter episodes preablation were asymptomatic, that proportion climbed to 79% post ablation. The ratio of asymptomatic-to-symptomatic AF episodes preablation was 1.1:1; postablation, it jumped to 3.7:1.

Similarly, 36% of the total AF/flutter burden patients shouldered preablation consisted of asymptomatic arrhythmias, while postablation 68% of the burden was asymptomatic. The ratio of asymptomatic-to-symptomatic AF/flutter burden preablation was 0.6:1; postablation, it was 2:1.

Patient self-reports corresponded to an implantable loop recorder–documented episode of AF only 47% of the time.

On the basis of self-reported symptoms only, 58% of patients were free of AF postablation. However, the implantable monitor data showed that the true figure was 46%. In other words, after AF ablation 12% of study participants had AF recurrences that were exclusively asymptomatic, Dr. Verma continued.

Asymptomatic episodes were shorter than symptomatic ones, lasting 4 and 6 hours, respectively. They also involved a significantly lower heart rate and less heart rate variability. In a multivariate analysis, all three of these factors were independent predictors of asymptomatic AF recurrences. But postablation recurrences were a threefold more powerful predictor of lack of symptoms than any of the other three predictors.

One plausible explanation for the increased proportion of asymptomatic AF episodes postablation is that the procedure results in denervation, although this hypothesis requires further investigation, according to the cardiologist.

Discussant Dr. Michael R. Gold called the finding that the proportion of asymptomatic episodes increases following AF ablation "very intriguing."

In addition, DISCERN AF made a point very similar to the key message of the Catheter Ablation vs. Antiarrhythmic Drug Therapy for AF (CABANA) pilot study presented at the 2010 annual meeting of the American College of Cardiology in Atlanta: "We’re not as good as we thought we were in terms of ablating AF," observed Dr. Gold, professor of medicine, chief of cardiology, and medical director of the heart and vascular center at the Medical University of South Carolina, Charleston.

Dr. Gold noted that in the CABANA pilot study, 66% of patients had experienced asymptomatic and/or symptomatic recurrences of AF, atrial flutter, or tachycardia at 12 months of follow-up postablation. That wasn’t significantly different from the 72% recurrence rate in patients assigned to drug therapy.

"The harder you look, the more arrhythmias you find," Dr. Gold observed. "Clearly, DISCERN AF and the CABANA pilot study point to the need for large-scale studies with long-term follow-up to help us understand the best long-term clinical strategies, such as anticoagulation, as well as how well we’re doing with ablation."

One such study is the full-scale CABANA trial, sponsored by the National Heart, Lung, and Blood Institute; St. Jude Medical; and Biosense Webster. It will involve 3,000 patients and 5 years of follow-up.

The DISCERN AF study was supported by Medtronic. Dr. Verma disclosed that he serves as an adviser to Medtronic and half a dozen other medical device and pharmaceutical companies.

SAN FRANCISCO – Declaring a patient ‘cured’ of atrial fibrillation on the basis of a lack of symptoms following atrial fibrillation ablation is definitely jumping the gun, the DISCERN AF study indicates.

Implantable loop recorders used in DISCERN AF (Discerning the Incidence of Symptomatic and Asymptomatic Episodes Post Radiofrequency Ablation of AF) clearly documented that the proportion of AF episodes that are asymptomatic markedly increases after ablation, Dr. Atul Verma reported at the annual meeting of the Heart Rhythm Society.

"There is something about the postablation state that is making patients less able to detect their arrhythmia," observed Dr. Verma, DISCERN AF principal investigator and an electrophysiologist at Southlake Regional Health Center in Newmarket, Ont.

DISCERN AF was an eight-center, prospective Canadian study in which 50 patients with symptomatic AF received a Medtronic Reveal XT insertable cardiac monitor at least 3 months before they underwent a standard first-time AF ablation procedure. Eighty percent of participants had paroxysmal AF. The subjects’ mean left atrial size was 41 mm. Dr. Verma presented the study results through 18 months of postablation follow-up, but there will be a subsequent report, because the devices will be left in place for a total of 30 months post ablation.

Patients kept a detailed standardized diary to record the exact times of onset and end of their arrhythmic symptoms. Every 3 months the implantable loop recorder data were downloaded, and all recorded episodes were blindly adjudicated and compared to entries in the symptom diaries.

Radiofrequency ablation (RF) effectively reduced total AF burden. Indeed, the total AF/atrial flutter burden decreased from a mean of 2 hours per day per patient preablation to 0.3 hours per day per patient post ablation, an 86% reduction. But while 52% of all AF/flutter episodes preablation were asymptomatic, that proportion climbed to 79% post ablation. The ratio of asymptomatic-to-symptomatic AF episodes preablation was 1.1:1; postablation, it jumped to 3.7:1.

Similarly, 36% of the total AF/flutter burden patients shouldered preablation consisted of asymptomatic arrhythmias, while postablation 68% of the burden was asymptomatic. The ratio of asymptomatic-to-symptomatic AF/flutter burden preablation was 0.6:1; postablation, it was 2:1.

Patient self-reports corresponded to an implantable loop recorder–documented episode of AF only 47% of the time.

On the basis of self-reported symptoms only, 58% of patients were free of AF postablation. However, the implantable monitor data showed that the true figure was 46%. In other words, after AF ablation 12% of study participants had AF recurrences that were exclusively asymptomatic, Dr. Verma continued.

Asymptomatic episodes were shorter than symptomatic ones, lasting 4 and 6 hours, respectively. They also involved a significantly lower heart rate and less heart rate variability. In a multivariate analysis, all three of these factors were independent predictors of asymptomatic AF recurrences. But postablation recurrences were a threefold more powerful predictor of lack of symptoms than any of the other three predictors.

One plausible explanation for the increased proportion of asymptomatic AF episodes postablation is that the procedure results in denervation, although this hypothesis requires further investigation, according to the cardiologist.

Discussant Dr. Michael R. Gold called the finding that the proportion of asymptomatic episodes increases following AF ablation "very intriguing."

In addition, DISCERN AF made a point very similar to the key message of the Catheter Ablation vs. Antiarrhythmic Drug Therapy for AF (CABANA) pilot study presented at the 2010 annual meeting of the American College of Cardiology in Atlanta: "We’re not as good as we thought we were in terms of ablating AF," observed Dr. Gold, professor of medicine, chief of cardiology, and medical director of the heart and vascular center at the Medical University of South Carolina, Charleston.

Dr. Gold noted that in the CABANA pilot study, 66% of patients had experienced asymptomatic and/or symptomatic recurrences of AF, atrial flutter, or tachycardia at 12 months of follow-up postablation. That wasn’t significantly different from the 72% recurrence rate in patients assigned to drug therapy.

"The harder you look, the more arrhythmias you find," Dr. Gold observed. "Clearly, DISCERN AF and the CABANA pilot study point to the need for large-scale studies with long-term follow-up to help us understand the best long-term clinical strategies, such as anticoagulation, as well as how well we’re doing with ablation."

One such study is the full-scale CABANA trial, sponsored by the National Heart, Lung, and Blood Institute; St. Jude Medical; and Biosense Webster. It will involve 3,000 patients and 5 years of follow-up.

The DISCERN AF study was supported by Medtronic. Dr. Verma disclosed that he serves as an adviser to Medtronic and half a dozen other medical device and pharmaceutical companies.

SAN FRANCISCO – Declaring a patient ‘cured’ of atrial fibrillation on the basis of a lack of symptoms following atrial fibrillation ablation is definitely jumping the gun, the DISCERN AF study indicates.

Implantable loop recorders used in DISCERN AF (Discerning the Incidence of Symptomatic and Asymptomatic Episodes Post Radiofrequency Ablation of AF) clearly documented that the proportion of AF episodes that are asymptomatic markedly increases after ablation, Dr. Atul Verma reported at the annual meeting of the Heart Rhythm Society.

"There is something about the postablation state that is making patients less able to detect their arrhythmia," observed Dr. Verma, DISCERN AF principal investigator and an electrophysiologist at Southlake Regional Health Center in Newmarket, Ont.

DISCERN AF was an eight-center, prospective Canadian study in which 50 patients with symptomatic AF received a Medtronic Reveal XT insertable cardiac monitor at least 3 months before they underwent a standard first-time AF ablation procedure. Eighty percent of participants had paroxysmal AF. The subjects’ mean left atrial size was 41 mm. Dr. Verma presented the study results through 18 months of postablation follow-up, but there will be a subsequent report, because the devices will be left in place for a total of 30 months post ablation.

Patients kept a detailed standardized diary to record the exact times of onset and end of their arrhythmic symptoms. Every 3 months the implantable loop recorder data were downloaded, and all recorded episodes were blindly adjudicated and compared to entries in the symptom diaries.

Radiofrequency ablation (RF) effectively reduced total AF burden. Indeed, the total AF/atrial flutter burden decreased from a mean of 2 hours per day per patient preablation to 0.3 hours per day per patient post ablation, an 86% reduction. But while 52% of all AF/flutter episodes preablation were asymptomatic, that proportion climbed to 79% post ablation. The ratio of asymptomatic-to-symptomatic AF episodes preablation was 1.1:1; postablation, it jumped to 3.7:1.

Similarly, 36% of the total AF/flutter burden patients shouldered preablation consisted of asymptomatic arrhythmias, while postablation 68% of the burden was asymptomatic. The ratio of asymptomatic-to-symptomatic AF/flutter burden preablation was 0.6:1; postablation, it was 2:1.

Patient self-reports corresponded to an implantable loop recorder–documented episode of AF only 47% of the time.

On the basis of self-reported symptoms only, 58% of patients were free of AF postablation. However, the implantable monitor data showed that the true figure was 46%. In other words, after AF ablation 12% of study participants had AF recurrences that were exclusively asymptomatic, Dr. Verma continued.

Asymptomatic episodes were shorter than symptomatic ones, lasting 4 and 6 hours, respectively. They also involved a significantly lower heart rate and less heart rate variability. In a multivariate analysis, all three of these factors were independent predictors of asymptomatic AF recurrences. But postablation recurrences were a threefold more powerful predictor of lack of symptoms than any of the other three predictors.

One plausible explanation for the increased proportion of asymptomatic AF episodes postablation is that the procedure results in denervation, although this hypothesis requires further investigation, according to the cardiologist.

Discussant Dr. Michael R. Gold called the finding that the proportion of asymptomatic episodes increases following AF ablation "very intriguing."

In addition, DISCERN AF made a point very similar to the key message of the Catheter Ablation vs. Antiarrhythmic Drug Therapy for AF (CABANA) pilot study presented at the 2010 annual meeting of the American College of Cardiology in Atlanta: "We’re not as good as we thought we were in terms of ablating AF," observed Dr. Gold, professor of medicine, chief of cardiology, and medical director of the heart and vascular center at the Medical University of South Carolina, Charleston.

Dr. Gold noted that in the CABANA pilot study, 66% of patients had experienced asymptomatic and/or symptomatic recurrences of AF, atrial flutter, or tachycardia at 12 months of follow-up postablation. That wasn’t significantly different from the 72% recurrence rate in patients assigned to drug therapy.

"The harder you look, the more arrhythmias you find," Dr. Gold observed. "Clearly, DISCERN AF and the CABANA pilot study point to the need for large-scale studies with long-term follow-up to help us understand the best long-term clinical strategies, such as anticoagulation, as well as how well we’re doing with ablation."

One such study is the full-scale CABANA trial, sponsored by the National Heart, Lung, and Blood Institute; St. Jude Medical; and Biosense Webster. It will involve 3,000 patients and 5 years of follow-up.

The DISCERN AF study was supported by Medtronic. Dr. Verma disclosed that he serves as an adviser to Medtronic and half a dozen other medical device and pharmaceutical companies.

SAN FRANCISCO – The incidence of pacemaker infections is climbing in the United States, while the rate of infections involving implantable cardioverter-defibrillators has remained fairly stable over time.

The incidence of infection in U.S. pacemaker recipients rose 224% during 1993-2008, from 1.6% to 3.5%, Jasmine Patel, Ph.D., reported at the annual meeting of the Heart Rhythm Society.

She examined trends over time in the infection burden related to pacemakers and ICDs by analyzing data from the National Inpatient Survey, a statistically valid annual survey of roughly 1,000 U.S. hospitals. During the period 1993-2008, an estimated 3.2 million patients received pacemakers and 1.1 million got ICDs.

Several comorbid conditions were related to an increased risk of infection in pacemaker recipients. Most notably, renal failure was associated with a 2.38-fold increased risk of infection.

At the same time, the epidemiology of renal failure is changing. In 2008, one-third of patients with an infected pacemaker or ICD had renal failure; in 1993 that was the case among only 3.6% of patients with an infected pacemaker and 2.8% of those with an ICD infection, according to Dr. Patel, a biomedical engineer in the Philadelphia office of Exponent, a large engineering and consulting firm.

Other comorbidities linked to pacemaker infection were respiratory failure, with an associated 2.25-fold increased risk; heart failure, with a 1.46-fold risk; and diabetes, which increased the risk of pacemaker site infection 1.12-fold.

The incidence of ICD-site infection was increased 2.18-fold with comorbid renal failure, 1.3-fold with respiratory failure, and 1.28-fold with heart failure.

Overall, the incidence of infection was 75% greater in pacemaker recipients than in patients with an ICD.

Dr. Mihaly de Bie of Leiden ( the Netherlands) University Medical Center reported that an ICD or cardiac resynchronization therapy defibrillator (CRT-D) device infection is associated with a twofold increased risk of mortality during the next year.

Among 2,574 patients who received an ICD or CRT-D at the medical center during January 2000 through September 2009, the incidence of a device infection during the first year post implant was 1.1%, climbing to 2.6% after 3 years.

The 1-year mortality following a first cardiac device infection was 14.4%. After adjustment for age, sex, diabetes, and renal clearance as potential confounding variables, a first cardiac device infection was associated with a 2.4-fold increased risk of mortality over the next year compared with patients who didn’t experience a device infection.

Dr. Patel and Dr. de Bie said they had no relevant financial disclosures.

SAN FRANCISCO – The incidence of pacemaker infections is climbing in the United States, while the rate of infections involving implantable cardioverter-defibrillators has remained fairly stable over time.

The incidence of infection in U.S. pacemaker recipients rose 224% during 1993-2008, from 1.6% to 3.5%, Jasmine Patel, Ph.D., reported at the annual meeting of the Heart Rhythm Society.

She examined trends over time in the infection burden related to pacemakers and ICDs by analyzing data from the National Inpatient Survey, a statistically valid annual survey of roughly 1,000 U.S. hospitals. During the period 1993-2008, an estimated 3.2 million patients received pacemakers and 1.1 million got ICDs.

Several comorbid conditions were related to an increased risk of infection in pacemaker recipients. Most notably, renal failure was associated with a 2.38-fold increased risk of infection.

At the same time, the epidemiology of renal failure is changing. In 2008, one-third of patients with an infected pacemaker or ICD had renal failure; in 1993 that was the case among only 3.6% of patients with an infected pacemaker and 2.8% of those with an ICD infection, according to Dr. Patel, a biomedical engineer in the Philadelphia office of Exponent, a large engineering and consulting firm.

Other comorbidities linked to pacemaker infection were respiratory failure, with an associated 2.25-fold increased risk; heart failure, with a 1.46-fold risk; and diabetes, which increased the risk of pacemaker site infection 1.12-fold.

The incidence of ICD-site infection was increased 2.18-fold with comorbid renal failure, 1.3-fold with respiratory failure, and 1.28-fold with heart failure.

Overall, the incidence of infection was 75% greater in pacemaker recipients than in patients with an ICD.

Dr. Mihaly de Bie of Leiden ( the Netherlands) University Medical Center reported that an ICD or cardiac resynchronization therapy defibrillator (CRT-D) device infection is associated with a twofold increased risk of mortality during the next year.

Among 2,574 patients who received an ICD or CRT-D at the medical center during January 2000 through September 2009, the incidence of a device infection during the first year post implant was 1.1%, climbing to 2.6% after 3 years.

The 1-year mortality following a first cardiac device infection was 14.4%. After adjustment for age, sex, diabetes, and renal clearance as potential confounding variables, a first cardiac device infection was associated with a 2.4-fold increased risk of mortality over the next year compared with patients who didn’t experience a device infection.

Dr. Patel and Dr. de Bie said they had no relevant financial disclosures.

SAN FRANCISCO – The incidence of pacemaker infections is climbing in the United States, while the rate of infections involving implantable cardioverter-defibrillators has remained fairly stable over time.

The incidence of infection in U.S. pacemaker recipients rose 224% during 1993-2008, from 1.6% to 3.5%, Jasmine Patel, Ph.D., reported at the annual meeting of the Heart Rhythm Society.

She examined trends over time in the infection burden related to pacemakers and ICDs by analyzing data from the National Inpatient Survey, a statistically valid annual survey of roughly 1,000 U.S. hospitals. During the period 1993-2008, an estimated 3.2 million patients received pacemakers and 1.1 million got ICDs.

Several comorbid conditions were related to an increased risk of infection in pacemaker recipients. Most notably, renal failure was associated with a 2.38-fold increased risk of infection.

At the same time, the epidemiology of renal failure is changing. In 2008, one-third of patients with an infected pacemaker or ICD had renal failure; in 1993 that was the case among only 3.6% of patients with an infected pacemaker and 2.8% of those with an ICD infection, according to Dr. Patel, a biomedical engineer in the Philadelphia office of Exponent, a large engineering and consulting firm.

Other comorbidities linked to pacemaker infection were respiratory failure, with an associated 2.25-fold increased risk; heart failure, with a 1.46-fold risk; and diabetes, which increased the risk of pacemaker site infection 1.12-fold.

The incidence of ICD-site infection was increased 2.18-fold with comorbid renal failure, 1.3-fold with respiratory failure, and 1.28-fold with heart failure.

Overall, the incidence of infection was 75% greater in pacemaker recipients than in patients with an ICD.

Dr. Mihaly de Bie of Leiden ( the Netherlands) University Medical Center reported that an ICD or cardiac resynchronization therapy defibrillator (CRT-D) device infection is associated with a twofold increased risk of mortality during the next year.

Among 2,574 patients who received an ICD or CRT-D at the medical center during January 2000 through September 2009, the incidence of a device infection during the first year post implant was 1.1%, climbing to 2.6% after 3 years.

The 1-year mortality following a first cardiac device infection was 14.4%. After adjustment for age, sex, diabetes, and renal clearance as potential confounding variables, a first cardiac device infection was associated with a 2.4-fold increased risk of mortality over the next year compared with patients who didn’t experience a device infection.

Dr. Patel and Dr. de Bie said they had no relevant financial disclosures.

SAN FRANCISCO – The incidence of pacemaker infections is climbing in the United States, while the rate of infections involving implantable cardioverter-defibrillators has remained fairly stable over time.

The incidence of infection in U.S. pacemaker recipients rose 224% during 1993-2008, from 1.6% to 3.5%, Jasmine Patel, Ph.D., reported at the annual meeting of the Heart Rhythm Society.

She examined trends over time in the infection burden related to pacemakers and ICDs by analyzing data from the National Inpatient Survey, a statistically valid annual survey of roughly 1,000 U.S. hospitals. During the period 1993-2008, an estimated 3.2 million patients received pacemakers and 1.1 million got ICDs.

Several comorbid conditions were related to an increased risk of infection in pacemaker recipients. Most notably, renal failure was associated with a 2.38-fold increased risk of infection.

At the same time, the epidemiology of renal failure is changing. In 2008, one-third of patients with an infected pacemaker or ICD had renal failure; in 1993 that was the case among only 3.6% of patients with an infected pacemaker and 2.8% of those with an ICD infection, according to Dr. Patel, a biomedical engineer in the Philadelphia office of Exponent, a large engineering and consulting firm.

Other comorbidities linked to pacemaker infection were respiratory failure, with an associated 2.25-fold increased risk; heart failure, with a 1.46-fold risk; and diabetes, which increased the risk of pacemaker site infection 1.12-fold.

The incidence of ICD-site infection was increased 2.18-fold with comorbid renal failure, 1.3-fold with respiratory failure, and 1.28-fold with heart failure.

Overall, the incidence of infection was 75% greater in pacemaker recipients than in patients with an ICD.

Dr. Mihaly de Bie of Leiden ( the Netherlands) University Medical Center reported that an ICD or cardiac resynchronization therapy defibrillator (CRT-D) device infection is associated with a twofold increased risk of mortality during the next year.

Among 2,574 patients who received an ICD or CRT-D at the medical center during January 2000 through September 2009, the incidence of a device infection during the first year post implant was 1.1%, climbing to 2.6% after 3 years.

The 1-year mortality following a first cardiac device infection was 14.4%. After adjustment for age, sex, diabetes, and renal clearance as potential confounding variables, a first cardiac device infection was associated with a 2.4-fold increased risk of mortality over the next year compared with patients who didn’t experience a device infection.

Dr. Patel and Dr. de Bie said they had no relevant financial disclosures.

SAN FRANCISCO – The incidence of pacemaker infections is climbing in the United States, while the rate of infections involving implantable cardioverter-defibrillators has remained fairly stable over time.

The incidence of infection in U.S. pacemaker recipients rose 224% during 1993-2008, from 1.6% to 3.5%, Jasmine Patel, Ph.D., reported at the annual meeting of the Heart Rhythm Society.

She examined trends over time in the infection burden related to pacemakers and ICDs by analyzing data from the National Inpatient Survey, a statistically valid annual survey of roughly 1,000 U.S. hospitals. During the period 1993-2008, an estimated 3.2 million patients received pacemakers and 1.1 million got ICDs.

Several comorbid conditions were related to an increased risk of infection in pacemaker recipients. Most notably, renal failure was associated with a 2.38-fold increased risk of infection.

At the same time, the epidemiology of renal failure is changing. In 2008, one-third of patients with an infected pacemaker or ICD had renal failure; in 1993 that was the case among only 3.6% of patients with an infected pacemaker and 2.8% of those with an ICD infection, according to Dr. Patel, a biomedical engineer in the Philadelphia office of Exponent, a large engineering and consulting firm.

Other comorbidities linked to pacemaker infection were respiratory failure, with an associated 2.25-fold increased risk; heart failure, with a 1.46-fold risk; and diabetes, which increased the risk of pacemaker site infection 1.12-fold.

The incidence of ICD-site infection was increased 2.18-fold with comorbid renal failure, 1.3-fold with respiratory failure, and 1.28-fold with heart failure.

Overall, the incidence of infection was 75% greater in pacemaker recipients than in patients with an ICD.

Dr. Mihaly de Bie of Leiden ( the Netherlands) University Medical Center reported that an ICD or cardiac resynchronization therapy defibrillator (CRT-D) device infection is associated with a twofold increased risk of mortality during the next year.

Among 2,574 patients who received an ICD or CRT-D at the medical center during January 2000 through September 2009, the incidence of a device infection during the first year post implant was 1.1%, climbing to 2.6% after 3 years.

The 1-year mortality following a first cardiac device infection was 14.4%. After adjustment for age, sex, diabetes, and renal clearance as potential confounding variables, a first cardiac device infection was associated with a 2.4-fold increased risk of mortality over the next year compared with patients who didn’t experience a device infection.

Dr. Patel and Dr. de Bie said they had no relevant financial disclosures.

SAN FRANCISCO – The incidence of pacemaker infections is climbing in the United States, while the rate of infections involving implantable cardioverter-defibrillators has remained fairly stable over time.

The incidence of infection in U.S. pacemaker recipients rose 224% during 1993-2008, from 1.6% to 3.5%, Jasmine Patel, Ph.D., reported at the annual meeting of the Heart Rhythm Society.

She examined trends over time in the infection burden related to pacemakers and ICDs by analyzing data from the National Inpatient Survey, a statistically valid annual survey of roughly 1,000 U.S. hospitals. During the period 1993-2008, an estimated 3.2 million patients received pacemakers and 1.1 million got ICDs.

Several comorbid conditions were related to an increased risk of infection in pacemaker recipients. Most notably, renal failure was associated with a 2.38-fold increased risk of infection.

At the same time, the epidemiology of renal failure is changing. In 2008, one-third of patients with an infected pacemaker or ICD had renal failure; in 1993 that was the case among only 3.6% of patients with an infected pacemaker and 2.8% of those with an ICD infection, according to Dr. Patel, a biomedical engineer in the Philadelphia office of Exponent, a large engineering and consulting firm.

Other comorbidities linked to pacemaker infection were respiratory failure, with an associated 2.25-fold increased risk; heart failure, with a 1.46-fold risk; and diabetes, which increased the risk of pacemaker site infection 1.12-fold.

The incidence of ICD-site infection was increased 2.18-fold with comorbid renal failure, 1.3-fold with respiratory failure, and 1.28-fold with heart failure.

Overall, the incidence of infection was 75% greater in pacemaker recipients than in patients with an ICD.

Dr. Mihaly de Bie of Leiden ( the Netherlands) University Medical Center reported that an ICD or cardiac resynchronization therapy defibrillator (CRT-D) device infection is associated with a twofold increased risk of mortality during the next year.

Among 2,574 patients who received an ICD or CRT-D at the medical center during January 2000 through September 2009, the incidence of a device infection during the first year post implant was 1.1%, climbing to 2.6% after 3 years.

The 1-year mortality following a first cardiac device infection was 14.4%. After adjustment for age, sex, diabetes, and renal clearance as potential confounding variables, a first cardiac device infection was associated with a 2.4-fold increased risk of mortality over the next year compared with patients who didn’t experience a device infection.

Dr. Patel and Dr. de Bie said they had no relevant financial disclosures.

SAN FRANCISCO – The incidence of pacemaker infections is climbing in the United States, while the rate of infections involving implantable cardioverter-defibrillators has remained fairly stable over time.

The incidence of infection in U.S. pacemaker recipients rose 224% during 1993-2008, from 1.6% to 3.5%, Jasmine Patel, Ph.D., reported at the annual meeting of the Heart Rhythm Society.

She examined trends over time in the infection burden related to pacemakers and ICDs by analyzing data from the National Inpatient Survey, a statistically valid annual survey of roughly 1,000 U.S. hospitals. During the period 1993-2008, an estimated 3.2 million patients received pacemakers and 1.1 million got ICDs.

Several comorbid conditions were related to an increased risk of infection in pacemaker recipients. Most notably, renal failure was associated with a 2.38-fold increased risk of infection.

At the same time, the epidemiology of renal failure is changing. In 2008, one-third of patients with an infected pacemaker or ICD had renal failure; in 1993 that was the case among only 3.6% of patients with an infected pacemaker and 2.8% of those with an ICD infection, according to Dr. Patel, a biomedical engineer in the Philadelphia office of Exponent, a large engineering and consulting firm.

Other comorbidities linked to pacemaker infection were respiratory failure, with an associated 2.25-fold increased risk; heart failure, with a 1.46-fold risk; and diabetes, which increased the risk of pacemaker site infection 1.12-fold.

The incidence of ICD-site infection was increased 2.18-fold with comorbid renal failure, 1.3-fold with respiratory failure, and 1.28-fold with heart failure.

Overall, the incidence of infection was 75% greater in pacemaker recipients than in patients with an ICD.

Dr. Mihaly de Bie of Leiden ( the Netherlands) University Medical Center reported that an ICD or cardiac resynchronization therapy defibrillator (CRT-D) device infection is associated with a twofold increased risk of mortality during the next year.

Among 2,574 patients who received an ICD or CRT-D at the medical center during January 2000 through September 2009, the incidence of a device infection during the first year post implant was 1.1%, climbing to 2.6% after 3 years.

The 1-year mortality following a first cardiac device infection was 14.4%. After adjustment for age, sex, diabetes, and renal clearance as potential confounding variables, a first cardiac device infection was associated with a 2.4-fold increased risk of mortality over the next year compared with patients who didn’t experience a device infection.

Dr. Patel and Dr. de Bie said they had no relevant financial disclosures.

SAN FRANCISCO – The incidence of pacemaker infections is climbing in the United States, while the rate of infections involving implantable cardioverter-defibrillators has remained fairly stable over time.

The incidence of infection in U.S. pacemaker recipients rose 224% during 1993-2008, from 1.6% to 3.5%, Jasmine Patel, Ph.D., reported at the annual meeting of the Heart Rhythm Society.

She examined trends over time in the infection burden related to pacemakers and ICDs by analyzing data from the National Inpatient Survey, a statistically valid annual survey of roughly 1,000 U.S. hospitals. During the period 1993-2008, an estimated 3.2 million patients received pacemakers and 1.1 million got ICDs.

Several comorbid conditions were related to an increased risk of infection in pacemaker recipients. Most notably, renal failure was associated with a 2.38-fold increased risk of infection.

At the same time, the epidemiology of renal failure is changing. In 2008, one-third of patients with an infected pacemaker or ICD had renal failure; in 1993 that was the case among only 3.6% of patients with an infected pacemaker and 2.8% of those with an ICD infection, according to Dr. Patel, a biomedical engineer in the Philadelphia office of Exponent, a large engineering and consulting firm.

Other comorbidities linked to pacemaker infection were respiratory failure, with an associated 2.25-fold increased risk; heart failure, with a 1.46-fold risk; and diabetes, which increased the risk of pacemaker site infection 1.12-fold.

The incidence of ICD-site infection was increased 2.18-fold with comorbid renal failure, 1.3-fold with respiratory failure, and 1.28-fold with heart failure.

Overall, the incidence of infection was 75% greater in pacemaker recipients than in patients with an ICD.

Dr. Mihaly de Bie of Leiden ( the Netherlands) University Medical Center reported that an ICD or cardiac resynchronization therapy defibrillator (CRT-D) device infection is associated with a twofold increased risk of mortality during the next year.

Among 2,574 patients who received an ICD or CRT-D at the medical center during January 2000 through September 2009, the incidence of a device infection during the first year post implant was 1.1%, climbing to 2.6% after 3 years.

The 1-year mortality following a first cardiac device infection was 14.4%. After adjustment for age, sex, diabetes, and renal clearance as potential confounding variables, a first cardiac device infection was associated with a 2.4-fold increased risk of mortality over the next year compared with patients who didn’t experience a device infection.

Dr. Patel and Dr. de Bie said they had no relevant financial disclosures.

SAN FRANCISCO – The incidence of pacemaker infections is climbing in the United States, while the rate of infections involving implantable cardioverter-defibrillators has remained fairly stable over time.

The incidence of infection in U.S. pacemaker recipients rose 224% during 1993-2008, from 1.6% to 3.5%, Jasmine Patel, Ph.D., reported at the annual meeting of the Heart Rhythm Society.

She examined trends over time in the infection burden related to pacemakers and ICDs by analyzing data from the National Inpatient Survey, a statistically valid annual survey of roughly 1,000 U.S. hospitals. During the period 1993-2008, an estimated 3.2 million patients received pacemakers and 1.1 million got ICDs.

Several comorbid conditions were related to an increased risk of infection in pacemaker recipients. Most notably, renal failure was associated with a 2.38-fold increased risk of infection.

At the same time, the epidemiology of renal failure is changing. In 2008, one-third of patients with an infected pacemaker or ICD had renal failure; in 1993 that was the case among only 3.6% of patients with an infected pacemaker and 2.8% of those with an ICD infection, according to Dr. Patel, a biomedical engineer in the Philadelphia office of Exponent, a large engineering and consulting firm.

Other comorbidities linked to pacemaker infection were respiratory failure, with an associated 2.25-fold increased risk; heart failure, with a 1.46-fold risk; and diabetes, which increased the risk of pacemaker site infection 1.12-fold.

The incidence of ICD-site infection was increased 2.18-fold with comorbid renal failure, 1.3-fold with respiratory failure, and 1.28-fold with heart failure.

Overall, the incidence of infection was 75% greater in pacemaker recipients than in patients with an ICD.

Dr. Mihaly de Bie of Leiden ( the Netherlands) University Medical Center reported that an ICD or cardiac resynchronization therapy defibrillator (CRT-D) device infection is associated with a twofold increased risk of mortality during the next year.

Among 2,574 patients who received an ICD or CRT-D at the medical center during January 2000 through September 2009, the incidence of a device infection during the first year post implant was 1.1%, climbing to 2.6% after 3 years.

The 1-year mortality following a first cardiac device infection was 14.4%. After adjustment for age, sex, diabetes, and renal clearance as potential confounding variables, a first cardiac device infection was associated with a 2.4-fold increased risk of mortality over the next year compared with patients who didn’t experience a device infection.

Dr. Patel and Dr. de Bie said they had no relevant financial disclosures.

SAN FRANCISCO – A history of atrial fibrillation independently more than triples the risk of a nonaccidental fall in the elderly, an emergency department study has shown.

Of 459 consecutive elderly patients who presented to a large emergency department with a chief complaint of a fall, 225 had a fall deemed to be nonaccidental – that is, a fall not explained by mitigating circumstances such as a loose paving stone or a collision with a skateboarder.

A history of atrial fibrillation (AF) was present in 20.4% of those with a nonaccidental fall, compared with 10.6% of the 234 elderly patients who presented with an accidental fall, Dr. Joya A. Ganguly reported at the annual meeting of the Heart Rhythm Society.

The study population had a median age of 81 years. Patients not older than that who had a nonaccidental fall were 3.36-fold more likely to have a history of AF, compared with those who had an accidental fall. However, among patients older than 81 years, a history of AF was only 1.3-fold more frequent in those with a nonaccidental fall, compared with an accidental fall, and this difference was not significant, according to Dr. Ganguly of the University of Utah, Salt Lake City.

Patients with a nonaccidental fall were an average of 4 years older than those who presented with an accidental fall. In addition to being more likely to have a history of AF, patients with a nonaccidental fall were also more likely to have a neurologic disorder and to be on three or more medications.

In contrast, there were no differences between patients in the nonaccidental and accidental fall groups in terms of blood pressure, heart rate, orthostatic hypotension, prior pacemaker placement, a history of heart failure, or the prevalence of AF at presentation, which was about 8% in both groups.

Dr. Ganguly concluded that these study findings suggest elderly patients with a history of AF might be good candidates for a fall prevention education program along the lines of the national program recently proposed by investigators at the University of Southern California as a cost-effective intervention (Clin. Geriatr. Med. 2010;26:751-66).

She said she had no relevant financial disclosures.

SAN FRANCISCO – A history of atrial fibrillation independently more than triples the risk of a nonaccidental fall in the elderly, an emergency department study has shown.

Of 459 consecutive elderly patients who presented to a large emergency department with a chief complaint of a fall, 225 had a fall deemed to be nonaccidental – that is, a fall not explained by mitigating circumstances such as a loose paving stone or a collision with a skateboarder.

A history of atrial fibrillation (AF) was present in 20.4% of those with a nonaccidental fall, compared with 10.6% of the 234 elderly patients who presented with an accidental fall, Dr. Joya A. Ganguly reported at the annual meeting of the Heart Rhythm Society.

The study population had a median age of 81 years. Patients not older than that who had a nonaccidental fall were 3.36-fold more likely to have a history of AF, compared with those who had an accidental fall. However, among patients older than 81 years, a history of AF was only 1.3-fold more frequent in those with a nonaccidental fall, compared with an accidental fall, and this difference was not significant, according to Dr. Ganguly of the University of Utah, Salt Lake City.

Patients with a nonaccidental fall were an average of 4 years older than those who presented with an accidental fall. In addition to being more likely to have a history of AF, patients with a nonaccidental fall were also more likely to have a neurologic disorder and to be on three or more medications.

In contrast, there were no differences between patients in the nonaccidental and accidental fall groups in terms of blood pressure, heart rate, orthostatic hypotension, prior pacemaker placement, a history of heart failure, or the prevalence of AF at presentation, which was about 8% in both groups.

Dr. Ganguly concluded that these study findings suggest elderly patients with a history of AF might be good candidates for a fall prevention education program along the lines of the national program recently proposed by investigators at the University of Southern California as a cost-effective intervention (Clin. Geriatr. Med. 2010;26:751-66).

She said she had no relevant financial disclosures.

SAN FRANCISCO – A history of atrial fibrillation independently more than triples the risk of a nonaccidental fall in the elderly, an emergency department study has shown.

Of 459 consecutive elderly patients who presented to a large emergency department with a chief complaint of a fall, 225 had a fall deemed to be nonaccidental – that is, a fall not explained by mitigating circumstances such as a loose paving stone or a collision with a skateboarder.

A history of atrial fibrillation (AF) was present in 20.4% of those with a nonaccidental fall, compared with 10.6% of the 234 elderly patients who presented with an accidental fall, Dr. Joya A. Ganguly reported at the annual meeting of the Heart Rhythm Society.

The study population had a median age of 81 years. Patients not older than that who had a nonaccidental fall were 3.36-fold more likely to have a history of AF, compared with those who had an accidental fall. However, among patients older than 81 years, a history of AF was only 1.3-fold more frequent in those with a nonaccidental fall, compared with an accidental fall, and this difference was not significant, according to Dr. Ganguly of the University of Utah, Salt Lake City.

Patients with a nonaccidental fall were an average of 4 years older than those who presented with an accidental fall. In addition to being more likely to have a history of AF, patients with a nonaccidental fall were also more likely to have a neurologic disorder and to be on three or more medications.

In contrast, there were no differences between patients in the nonaccidental and accidental fall groups in terms of blood pressure, heart rate, orthostatic hypotension, prior pacemaker placement, a history of heart failure, or the prevalence of AF at presentation, which was about 8% in both groups.

Dr. Ganguly concluded that these study findings suggest elderly patients with a history of AF might be good candidates for a fall prevention education program along the lines of the national program recently proposed by investigators at the University of Southern California as a cost-effective intervention (Clin. Geriatr. Med. 2010;26:751-66).

She said she had no relevant financial disclosures.

SAN FRANCISCO – A history of atrial fibrillation independently more than triples the risk of a nonaccidental fall in the elderly, an emergency department study has shown.

Of 459 consecutive elderly patients who presented to a large emergency department with a chief complaint of a fall, 225 had a fall deemed to be nonaccidental – that is, a fall not explained by mitigating circumstances such as a loose paving stone or a collision with a skateboarder.

A history of atrial fibrillation (AF) was present in 20.4% of those with a nonaccidental fall, compared with 10.6% of the 234 elderly patients who presented with an accidental fall, Dr. Joya A. Ganguly reported at the annual meeting of the Heart Rhythm Society.

The study population had a median age of 81 years. Patients not older than that who had a nonaccidental fall were 3.36-fold more likely to have a history of AF, compared with those who had an accidental fall. However, among patients older than 81 years, a history of AF was only 1.3-fold more frequent in those with a nonaccidental fall, compared with an accidental fall, and this difference was not significant, according to Dr. Ganguly of the University of Utah, Salt Lake City.

Patients with a nonaccidental fall were an average of 4 years older than those who presented with an accidental fall. In addition to being more likely to have a history of AF, patients with a nonaccidental fall were also more likely to have a neurologic disorder and to be on three or more medications.

In contrast, there were no differences between patients in the nonaccidental and accidental fall groups in terms of blood pressure, heart rate, orthostatic hypotension, prior pacemaker placement, a history of heart failure, or the prevalence of AF at presentation, which was about 8% in both groups.

Dr. Ganguly concluded that these study findings suggest elderly patients with a history of AF might be good candidates for a fall prevention education program along the lines of the national program recently proposed by investigators at the University of Southern California as a cost-effective intervention (Clin. Geriatr. Med. 2010;26:751-66).

She said she had no relevant financial disclosures.

SAN FRANCISCO – A history of atrial fibrillation independently more than triples the risk of a nonaccidental fall in the elderly, an emergency department study has shown.

Of 459 consecutive elderly patients who presented to a large emergency department with a chief complaint of a fall, 225 had a fall deemed to be nonaccidental – that is, a fall not explained by mitigating circumstances such as a loose paving stone or a collision with a skateboarder.

A history of atrial fibrillation (AF) was present in 20.4% of those with a nonaccidental fall, compared with 10.6% of the 234 elderly patients who presented with an accidental fall, Dr. Joya A. Ganguly reported at the annual meeting of the Heart Rhythm Society.

The study population had a median age of 81 years. Patients not older than that who had a nonaccidental fall were 3.36-fold more likely to have a history of AF, compared with those who had an accidental fall. However, among patients older than 81 years, a history of AF was only 1.3-fold more frequent in those with a nonaccidental fall, compared with an accidental fall, and this difference was not significant, according to Dr. Ganguly of the University of Utah, Salt Lake City.

Patients with a nonaccidental fall were an average of 4 years older than those who presented with an accidental fall. In addition to being more likely to have a history of AF, patients with a nonaccidental fall were also more likely to have a neurologic disorder and to be on three or more medications.

In contrast, there were no differences between patients in the nonaccidental and accidental fall groups in terms of blood pressure, heart rate, orthostatic hypotension, prior pacemaker placement, a history of heart failure, or the prevalence of AF at presentation, which was about 8% in both groups.

Dr. Ganguly concluded that these study findings suggest elderly patients with a history of AF might be good candidates for a fall prevention education program along the lines of the national program recently proposed by investigators at the University of Southern California as a cost-effective intervention (Clin. Geriatr. Med. 2010;26:751-66).

She said she had no relevant financial disclosures.

SAN FRANCISCO – A history of atrial fibrillation independently more than triples the risk of a nonaccidental fall in the elderly, an emergency department study has shown.

Of 459 consecutive elderly patients who presented to a large emergency department with a chief complaint of a fall, 225 had a fall deemed to be nonaccidental – that is, a fall not explained by mitigating circumstances such as a loose paving stone or a collision with a skateboarder.

A history of atrial fibrillation (AF) was present in 20.4% of those with a nonaccidental fall, compared with 10.6% of the 234 elderly patients who presented with an accidental fall, Dr. Joya A. Ganguly reported at the annual meeting of the Heart Rhythm Society.

The study population had a median age of 81 years. Patients not older than that who had a nonaccidental fall were 3.36-fold more likely to have a history of AF, compared with those who had an accidental fall. However, among patients older than 81 years, a history of AF was only 1.3-fold more frequent in those with a nonaccidental fall, compared with an accidental fall, and this difference was not significant, according to Dr. Ganguly of the University of Utah, Salt Lake City.

Patients with a nonaccidental fall were an average of 4 years older than those who presented with an accidental fall. In addition to being more likely to have a history of AF, patients with a nonaccidental fall were also more likely to have a neurologic disorder and to be on three or more medications.

In contrast, there were no differences between patients in the nonaccidental and accidental fall groups in terms of blood pressure, heart rate, orthostatic hypotension, prior pacemaker placement, a history of heart failure, or the prevalence of AF at presentation, which was about 8% in both groups.

Dr. Ganguly concluded that these study findings suggest elderly patients with a history of AF might be good candidates for a fall prevention education program along the lines of the national program recently proposed by investigators at the University of Southern California as a cost-effective intervention (Clin. Geriatr. Med. 2010;26:751-66).

She said she had no relevant financial disclosures.

SAN FRANCISCO – A history of atrial fibrillation independently more than triples the risk of a nonaccidental fall in the elderly, an emergency department study has shown.

Of 459 consecutive elderly patients who presented to a large emergency department with a chief complaint of a fall, 225 had a fall deemed to be nonaccidental – that is, a fall not explained by mitigating circumstances such as a loose paving stone or a collision with a skateboarder.

A history of atrial fibrillation (AF) was present in 20.4% of those with a nonaccidental fall, compared with 10.6% of the 234 elderly patients who presented with an accidental fall, Dr. Joya A. Ganguly reported at the annual meeting of the Heart Rhythm Society.

The study population had a median age of 81 years. Patients not older than that who had a nonaccidental fall were 3.36-fold more likely to have a history of AF, compared with those who had an accidental fall. However, among patients older than 81 years, a history of AF was only 1.3-fold more frequent in those with a nonaccidental fall, compared with an accidental fall, and this difference was not significant, according to Dr. Ganguly of the University of Utah, Salt Lake City.

Patients with a nonaccidental fall were an average of 4 years older than those who presented with an accidental fall. In addition to being more likely to have a history of AF, patients with a nonaccidental fall were also more likely to have a neurologic disorder and to be on three or more medications.

In contrast, there were no differences between patients in the nonaccidental and accidental fall groups in terms of blood pressure, heart rate, orthostatic hypotension, prior pacemaker placement, a history of heart failure, or the prevalence of AF at presentation, which was about 8% in both groups.

Dr. Ganguly concluded that these study findings suggest elderly patients with a history of AF might be good candidates for a fall prevention education program along the lines of the national program recently proposed by investigators at the University of Southern California as a cost-effective intervention (Clin. Geriatr. Med. 2010;26:751-66).

She said she had no relevant financial disclosures.

SAN FRANCISCO – A history of atrial fibrillation independently more than triples the risk of a nonaccidental fall in the elderly, an emergency department study has shown.

Of 459 consecutive elderly patients who presented to a large emergency department with a chief complaint of a fall, 225 had a fall deemed to be nonaccidental – that is, a fall not explained by mitigating circumstances such as a loose paving stone or a collision with a skateboarder.

A history of atrial fibrillation (AF) was present in 20.4% of those with a nonaccidental fall, compared with 10.6% of the 234 elderly patients who presented with an accidental fall, Dr. Joya A. Ganguly reported at the annual meeting of the Heart Rhythm Society.

The study population had a median age of 81 years. Patients not older than that who had a nonaccidental fall were 3.36-fold more likely to have a history of AF, compared with those who had an accidental fall. However, among patients older than 81 years, a history of AF was only 1.3-fold more frequent in those with a nonaccidental fall, compared with an accidental fall, and this difference was not significant, according to Dr. Ganguly of the University of Utah, Salt Lake City.

Patients with a nonaccidental fall were an average of 4 years older than those who presented with an accidental fall. In addition to being more likely to have a history of AF, patients with a nonaccidental fall were also more likely to have a neurologic disorder and to be on three or more medications.

In contrast, there were no differences between patients in the nonaccidental and accidental fall groups in terms of blood pressure, heart rate, orthostatic hypotension, prior pacemaker placement, a history of heart failure, or the prevalence of AF at presentation, which was about 8% in both groups.

Dr. Ganguly concluded that these study findings suggest elderly patients with a history of AF might be good candidates for a fall prevention education program along the lines of the national program recently proposed by investigators at the University of Southern California as a cost-effective intervention (Clin. Geriatr. Med. 2010;26:751-66).

She said she had no relevant financial disclosures.

SAN FRANCISCO – A history of atrial fibrillation independently more than triples the risk of a nonaccidental fall in the elderly, an emergency department study has shown.

Of 459 consecutive elderly patients who presented to a large emergency department with a chief complaint of a fall, 225 had a fall deemed to be nonaccidental – that is, a fall not explained by mitigating circumstances such as a loose paving stone or a collision with a skateboarder.

A history of atrial fibrillation (AF) was present in 20.4% of those with a nonaccidental fall, compared with 10.6% of the 234 elderly patients who presented with an accidental fall, Dr. Joya A. Ganguly reported at the annual meeting of the Heart Rhythm Society.

The study population had a median age of 81 years. Patients not older than that who had a nonaccidental fall were 3.36-fold more likely to have a history of AF, compared with those who had an accidental fall. However, among patients older than 81 years, a history of AF was only 1.3-fold more frequent in those with a nonaccidental fall, compared with an accidental fall, and this difference was not significant, according to Dr. Ganguly of the University of Utah, Salt Lake City.

Patients with a nonaccidental fall were an average of 4 years older than those who presented with an accidental fall. In addition to being more likely to have a history of AF, patients with a nonaccidental fall were also more likely to have a neurologic disorder and to be on three or more medications.

In contrast, there were no differences between patients in the nonaccidental and accidental fall groups in terms of blood pressure, heart rate, orthostatic hypotension, prior pacemaker placement, a history of heart failure, or the prevalence of AF at presentation, which was about 8% in both groups.

Dr. Ganguly concluded that these study findings suggest elderly patients with a history of AF might be good candidates for a fall prevention education program along the lines of the national program recently proposed by investigators at the University of Southern California as a cost-effective intervention (Clin. Geriatr. Med. 2010;26:751-66).

She said she had no relevant financial disclosures.