Long‐Term Pharmacologic Management of Atrial Fibrillation in the Elderly

The first decision to be made in treating atrial fibrillation in the elderly is to determine whether to pursue a treatment strategy of rate control or rhythm control. Both strategies require use of anticoagulation therapy with warfarin (target international normalized ratio, 2.5; range 2-3). If a decision is made for rhythm control, the critical therapy is almost always with an antiarrhythmic drug. Before selecting an antiarrhythmic drug for use, it is first necessary to determine the presence or absence of underlying structural heart disease, as that will affect the available options for antiarrhythmic drug use. If there is no underlying structural heart disease, any of the available antiarrhythmic drugs may be used, although a clinically reasoned approach is suggested. If there is underlying structural heart disease, not all antiarrhythmic drugs are appropriate for use. A clinically reasoned approach is suggested in the presence of coronary artery disease, left ventricular dysfunction /congestive heart failure, or hypertension based largely on the risk/benefit profile of the drugs.