Atrial fibrillation is common in the elderly and requires an individualized treatment approach balancing stroke and bleeding risks. Rate control is generally recommended for those over age 80, while rhythm control may be suitable for highly symptomatic or younger patients with few comorbidities. Anticoagulation reduces stroke risk but requires consideration of frailty, cognition, polypharmacy, nutrition, and life expectancy. Novel oral anticoagulants offer advantages over warfarin for the elderly due to fewer drug interactions and more predictable dosing.

1. Atrial Fibrillation in Elderly
Dr.
Ayman Noureldin
Professor of Cardiology

3. AF in elderly management

4. Rate versus rhythm control in elderly
• Debate. A variety of studies have shown clear
benefits with either therapy.
• Therapy should be individualized based on the
clinical scenario and associated comorbidities.
• > 80 y Rate control
Proarrhythmic side effects, higher rate of
persistent AF and permanent AF with significant
left atrial enlargement.

5. EAST-AFNET 4 trial
• Conclusion: Early rhythm-control therapy was associated with
a lower risk of adverse cardiovascular outcomes than usual
care among patients with early atrial fibrillation (< 12month)
and cardiovascular conditions.

6. Rate versus rhythm control
–Rate control: mild symptoms, good LV function
–Rhythm control:
 Highly symptomatic patients
 Paroxysmal AF and/or new-onset AF
 Heart failure exacerbated by AF or AF related
cardiomyopathy.
 Younger ptn with relatively few medical
comorbidities

7. ANTIARRHYTHMIC DRUGS IN ELDERLY
Rate control :
• β-blockers: 1st line
• Digoxin: in AF with heart failure not controlled with B-blocker,
and should be used cautiously in the elderly in whom renal
function is delicate.
Rhythm control :
• Cardioversion, whether electrical or pharmaceutical
• AF <= 48 hours, and OAC for at least 3 weeks.
• Amiodarone: safest
- Patients with an elevated stroke risk should receive
anticoagulation irrespective of the rate vs. rhythm management
strategy

8. Anticoagulation
• Stroke risk
• Risk and benefits
• Baseline kidney function
• Cognitive status, mobility and falling risk
• Multiple medication
• Nutritional status
• Life expectancy.

9. Reasons not to prescribe anticoagulant

10. Thromboembolic and bleeding risk

11. Warfarin vs NOAC
• Monitoring
• Drug- drug interaction
• Time in therapeutic range (TRT): suboptimal if
less than 65%.
• labile INR

12. Atrial fibrillation trials

19. Anticoagulation in elderly
• The challenge in elderly is whether the benefit of anticoagulant
treatment outweigh the associated risk of bleeding.
• Stroke and bleeding risk factors overlap
• Oral anticoagulation prevents 2/3 of all ischemic strokes in AF
patients compared to placebo or aspirin.
• Bleeding on anticoagulation is less common than stroke without
anticoagulation (stroke rate 1-2%/y in AF patients on OAC)
• Older AF patients have better outcomes on OAC than not and on
NOAC rather than VKA
• The risk of ICH is lower with all NOAC compared to VKA.

20. Frailty
• Frailty increases stroke risk but not major bleeding risk
• Anticoagulation in frail should be considered because of
their increased vulnerability and higher functional
worsening risk and disability.

22. benefit in patients with high risk exceeds the risk of falls.

23. Cognitive impairment
• Dementia is not a contraindication for anticoagulation
(consider severity, life expectancy, and adherence to therapy)
• Elderly patients with mild to moderate cognitive impairment
(“Global Deterioration Scale” or GDS <5) have not increased
bleeding risk and may receive OAC.
• Severe cognitive impairment (GDS 6–7), consider not initiating
OAC after discussion with family.
• Labile INR with VKA ( consider NOACs )

24. Polypharmacy
• Chronic administration of five or more drugs
• Risk of interactions (Warfarin)
• NOACs interact with fewer drugs: dependent on P-
glycoprotein (Pgp) transport for intestinal
absorption.
- P-glycoprotein (Pgp) transport inhibitors
(amiodarone, ketoconazole, quinidine and verapamil)
increase absorption and plasma concentration of
DOACs.

25. Nutritional status
• Protein deficit and hypoalbuminemia raise
plasma OAC concentration and, bleeding risk.
• Unlike VKA, NOACs do not interact with elements of
the diet.
• No dose modification for rivaroxaban or dabigatran
in patients with low weight (consider NOACs Plasma
level).
• <60 kg, the edoxaban dose (30 mg/24 h) and is one
of the two criteria necessary to recommend the
dose reduction of apixaban (2.5 mg/12 h)

26. Life expectancy
• Not only based on age but also considering
function, frailty, and comorbidity
• It may be reasonable to withhold oral
anticoagulation when life expectancy is less
than 6 months.

27. Comorbidity

28. AF in liver disease

29. Left atrial appendage closure

30. Conclusion
• AF is associated with five times the risk of stroke and is
responsible for up to 25% of strokes in elderly adults.
• The risk of stroke and bleeding should be carried out on
individual basis.
• NOACs as effective as warfarin, or in some cases superior,
with an overall better safety profile, consistently reducing
rates of intracranial hemorrhages
• NOACs are effective and safe when used at appropriate
dose
• Aspirin has no benefit in AF.