The elderly are
under represented in clinical trials. This review summarizes
the available evidence for the management of AF in the elderly. The
conclusions of this evidence synthesis are in line with current AF
recommendations in general:
Stroke prophylaxis
Elderly adults with AF are at greater risk than those without AF of stroke without anticoagulation and greater risk of bleeding with anticoagulation, posing a therapeutic challenge
Studies assessing the net clinical benefit of anticoagulation (which weighs the risk of ischemic stroke against the risk of major bleeding) demonstrate a significant benefit of anticoagulation in most elderly adults
Recently available direct oral anticoagulants may tip the balance further in favor of anticoagulation by reducing the rate of major bleeding, in particular intracranial hemorrhage
Evidence to support antiplatelet therapy for AF stroke prophylaxis is relatively weak, and in general, antiplatelet agents should have a limited role
In elderly adults who are unable to undergo long-term anticoagulation, percutaneous left atrial appendage occlusion devices may provide a reasonable alternative, although data are still emerging in this area
Symptom management
As a routine strategy, there is no benefit of rhythm control (using anti-arrhythmic drugs, cardioversion, or both) over rate control with AV nodal blocking agents
In individuals treated using rate control, a lenient strategy (target resting heart rate less than 110 bpm) is as effective for symptom control as strict rate control (target resting heart rate less than 80)
Individuals who cannot tolerate rate-slowing agents or those with tachycardia–bradycardia syndrome may benefit from pacemaker implantation plus AV nodal blocking drugs or ablation of the AV node
AF catheter ablation may be beneficial in appropriately selected elderly adults with inadequately controlled symptoms on medical therapy, although data on outcomes of ablation in elderly adults are limited
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