Evidence and uncertainties in the management of atrial fibrillation in the elderly

Paoló Alboni; Mario Bo; Stefano Fumagalli; Francesco Vetta; Enrico Brunetti; Samuele Baldasseroni; Alessandro Boccanelli; Giovambattista Desideri; Niccolò Marchionni; Renzo Rozzini; Pierfranco Terrosu; Andrea Ungar; Giovanni Zito

doi:10.23736/s0026-4806.21.07525-x

January 20, 2022Minerva Medica

Evidence and uncertainties in the management of atrial fibrillation in the elderly

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Why the study?

Older people carry the greatest burden of AF, but clinical management requires addressing evidence and uncertainties across oral anticoagulation, left atrial appendage occlusion, catheter ablation, and rhythm control strategies.

Key Points

To review clinical evidence, procedural indications, and management challenges for older patients diagnosed with atrial fibrillation.
Synthesized evidence evaluating oral anticoagulation, left atrial appendage occlusion (LAAO), catheter ablation (CA), and rhythm control strategies in older cohorts.
Assessed tailored management frameworks that incorporate geriatric syndromes and personalized risk-benefit profiling.
Oral anticoagulants serve as the primary therapy for preventing ischemic stroke, while interventions such as LAAO, CA, and rhythm control show clinical potential in lowering AF-related complications in selected elderly patients.
Achieving optimal clinical benefit requires comprehensive geriatric evaluation and shared decision-making to minimize therapeutic harm and procedural futility.

Structured PICO

P

Population

Elderly patients with atrial fibrillation

I

Intervention

Management strategies including oral anticoagulant therapy, left atrial appendage occlusion (LAAO), catheter ablation (CA), and rhythm control strategy (RCS)

A comprehensive assessment and shared decision-making process are essential for managing atrial fibrillation in older patients to maximize clinical benefit and avoid harm.

Implication

Patient-centered AF management in older adults warrants comprehensive geriatric assessment; leaves open optimal LAAO/ablation integration pending targeted trials.

Abstract

Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, whose incidence and prevalence increase with age, representing a significant burden for health services in western countries. Older people contribute to most patients affected from AF. Although oral anticoagulant therapy represents the cornerstone for the prevention of ischemic stroke and its disabling consequences, several other interventions - including left atrial appendage occlusion (LAAO), catheter ablation (CA) of AF, and rhythm control strategy (RCS) - have proved to be potentially effective in reducing the incidence of AF-associated clinical complications. Scientific literature focused on the three items will be discussed. Practical treatment of older AF patients is presented, including approach and management of patients with geriatric syndromes, selection of the most appropriate individualized drug treatment, clinical indications, and potential clinical benefit of LAAO and CA in selected older AF patients. Older people carry the greatest burden of AF in real world practice. Within a shared decision-making process, the patient centered approach needs to be put in the context of a comprehensive assessment, in order to gain maximal net clinical benefit and avoid futility or harm.