Atrial fibrillation in the elderly

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Opinion statement

Atrial fibrillation (AF) is the most common sustained arrhythmia in adults, and its incidence and prevalence increase progressively with age. As a result, AF-associated morbidity and mortality increase with age. Therefore, because even asymptomatic AF markedly increases the risk of stroke and other embolic events, aggressive treatment is warranted in order to avoid the potentially devastating sequelae of this condition. Goals for the treatment of AF in the elderly population should primarily focus on alleviation of symptoms and prevention of strokes, while minimizing potential toxic effects of polypharmacy. Rate control should be optimized with atrioventricular (AV) nodal-blocking agents. The decision of anticoagulation should be individualized for each patient, balancing the risk of stroke against the risk for major bleeding complications. In elderly patients without symptoms, rate control and anticoagulation is the preferred method of treatment. Antiarrhythmic therapy to maintain sinus rhythm is generally reserved for patients with significant symptoms attributable to AF. However, simply maintaining sinus rhythm has not been proven to decrease stroke risk; therefore, longterm anticoagulation is recommended even in patients who are in sinus rhythm on antiarrhythmic drugs. AV nodal ablation with implantation of a pacemaker is a safe and excellent method of rate control for elderly patients who do not respond adequately to pharmacotherapy. Other invasive procedures, such as pulmonary vein isolation and Cox-Maze operations, are associated with high risks of complications in the elderly and are generally not recommended. Postoperative AF is common in the elderly population, and its development in high-risk patients should be anticipated and promptly treated to avoid potential hemodynamic compromise and prolonged hospitalization.