Atrial fibrillation (AF) is the most common arrhythmia in elderly patients. Antiarrhythmic drugs (AADs) are often required for rate/rhythm control and to improve AF-related symptoms. There is limited evidence on the effectiveness and safety of AADs in elderly AF patients. This narrative review focuses on the use of AADs in elderly AF patients, summarizing the different physiology, pharmacokinetics and pharmacodynamics in the older age. Furthermore, the evidence from clinical studies on AADs pointing up data on safety and effectiveness in elderly was summarized. Although AADs represent a cornerstone for symptoms relief in patients with AF, these drugs did not show a clinical net benefit compared to a rate control, with a potential increased risk of complications and hospitalizations. Considered also the different pharmacokinetics and the concomitant comorbidities and treatments that characterize older patients, the administration of these drugs should be reserved to selected patients with high burden of AF-related symptoms.
Menichelli et al. (2025) studied this question.