Rate versus rhythm control in atrial fibrillation in the geriatric population — clinical outcomes, comorbidities, and therapeutic implications

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with a prevalence exceeding 10% in individuals > 75 years of age. In elderly patients, AF is associated with an increased risk of stroke, heart failure, hospitalization, and cognitive decline. The optimal management strategy — rate control versus rhythm control — remains controversial, particularly in the context of multimorbidity, frailty, and polypharmacy. Classic randomized trials demonstrated no significant survival benefit of rhythm control over rate control. However, contemporary studies suggest that early rhythm control may improve cardiovascular outcomes, including reductions in stroke and hospitalizations for heart failure. This narrative review summarizes current evidence with a focus on elderly patients, emphasizing clinical end points, comorbidities, aging-related changes, and pharmacological considerations. Individualized treatment and shared decision-making remain essential in this heterogeneous population.