Management of Atrial Fibrillation in Elderly Patients: A Whole New Ballgame?

Abstract

Atrial fibrillation (AF) is the most prevalent sustained supraventricular arrhythmia, particularly in older adults, with its incidence increasing dramatically with age. This condition is a significant contributor to morbidity and mortality, being closely linked to an elevated risk of heart failure, ischemic stroke, systemic thromboembolism, and dementia. The complexities of managing AF in the elderly arise from age-related physiological changes, comorbidities, frailty, and the challenges of polypharmacy. Therapeutic strategies must balance efficacy and safety, tailoring interventions to the individual's health status, life expectancy, and personal preferences. This review explores the latest evidence-based approaches to managing AF in elderly patients, focusing on the nuanced application of rate and rhythm control strategies, anticoagulation, and emerging insights into the relationship between AF and cognitive impairment.

Keywords: anticoagulation; atrial fibrillation (AF); cognitive decline; elderly patients; heart failure (HF); rate control; rhythm control.

Figure 1

PRISMA diagram on the selection of included studies.

Figure 2

AF development in the elderly. This figure illustrates the multifactorial pathophysiology underlying AF development in the elderly. It highlights the key risk factors contributing to atrial remodelling and chaotic electrical activity, ultimately leading to the onset of AF. In the figure are illustrated several well-established risk factors for AF, including obstructive sleep apnea, AH, DM, physical inactivity, coronary artery disease, heart failure, chronic kidney disease, and cognitive and functional status. These factors are known to play a critical role in promoting structural and electrical changes in the atria. The pathological changes that occur within the atrial myocardium, such as increased atrial size, atrial fibrosis, impaired contractility, fatty infiltration, and inflammation are shown. These structural alterations create a substrate that is prone to abnormal electrical conduction and re-entry circuits. ↑: Increase; ↓: Reduction.

Figure 3

Advantages and disadvantages of rate control and rhythm control strategies in the elderly. This figure illustrates the comparative upsides and downsides of two management strategies for AF in elderly patients. Rate control is associated with a lower risk of adverse events, which is particularly beneficial for elderly patients with multiple comorbidities. Although adjustments and periodic monitoring are required, the extent is generally lower than rhythm control, which is advantageous for elderly individuals. This strategy is more straightforward to achieve and maintain over the long term, fitting the needs of elderly patients who may have limited mobility. Elderly patients often need continuous anticoagulation therapy to mitigate the risk of thromboembolism, which can increase the risk of bleeding. Some elderly patients may continue to experience symptoms despite adequate rate control, affecting their quality of life. The rhythm control strategy effectively alleviates symptoms associated with AF, thereby enhancing the quality of life for elderly patients who are symptomatic despite rate control. However, elderly patients are more prone to experiencing recurrent episodes of AF. The procedural risks and potential complications related to CA or ECV are heightened in elderly patients due to age-related frailty and comorbidities. In summary, while rate control offers a safer and more manageable approach with fewer monitoring requirements, it may not fully resolve symptoms. Conversely, rhythm control can improve symptoms but carries a higher risk of recurrence and procedural complications, which are more pronounced in the elderly population.

Figure 4

Practical framework for optimizing the management of AF in elderly patients.