96 enzyme inhibitors, angiotensin receptor blockers, aldosterone inhibitors, statins and polyunsaturated fatty acids (PUFA) of the Omega 3 group, may contribute to the maintenance of the sinus rhythm through different mechanisms, but they lack adequate and consistent studies for their application in all patients.[63] For patients where the option was not to use cardioversion, or when it fails, heart rate is controlled to prevent tachy- cardiamiopathy. Drugs to be used should be those with specific actions on the atrioventricular node, such as betablockers, calcium channel blockers (verapamil or diltiazem), digoxin or amiodarone. Heart rate control aims at maintaining ven- tricular rate at rest between 60 to 80 beats per minute and between 90 and 115 beats at moderate exercise.[64] In the elderly with persistent AF heart rate, control is recommended if patients are asymptomatic (recommendation class I evidence level A of European Guidelines (Figure 4).[65] In situations refractory to heart rate control, atrio ventricular node modification by radiofrequency is indicated. For patients with Wolf-Parkinson-White (WPW) syndrome developing AF, drugs with more specific action on the anomalous pathway should be used (amiodarone, propafenone or procainamide), however, the first option should be anomalous pathway ablation. For acute AF and WPW patients, the first option is electrical cardioversion, which is safer than drugs. In 1998, Haissaguerre proposed for the first time the catheter ablation of AF.[66] Since that date, studies have enhanced the technique and tried to compare it to the use of antiarrhythmic drugs. Noheria et al.[67] have published a meta-analysis showing better results with ablation with regard to survival and arrhythmia recurrence. Currently, the ablation is made by electrical insulation of the opening of pulmonary veins in the left atrium eliminating the primary arrhythmia maintenance circuit. Figure 4. Choice of antiarrhythmic drug to maintain sinusal rhythm after AF cardioversion.[70] Franken RA et al. Atrial fibrillation in the elderly Recent studies have shown that radiofrequency ablation is more effective in maintaining sinus rhythm after drug failure in adults without significant structural heart disease and patients suffering of paroxysmal or permanent non- valvar AF.[68] Thus far, ablation should be reserved for selected groups of patients and be more restricted in the elderly due to the risk of procedure complications. Studies have included paroxystic, symptomatic AF patients with little or no struc- tural heart alteration. Based on presented information, the Brazilian Society of Cardiac Arrhythmias (SOBRAC) guidelines[69] and recent considerations of European and American guidelines, we have the following approaches for the elderly in AF or flutter. According to the Brazilian Cardiogeriatrics Guidelines,[70] recommendations for treating AF are as follows, (Figure 5). 4.1 Anti-thrombotic therapy in AF patients Class I: (1) anti-thrombotic therapy (INR between 2.0 and 3.0) for undefined time, except if there are contrain- dications; (2) oral anticoagulant for secondary prevention (acute encephalic accident, transitory ischemic attack, previous systemic embolization) in patients with rheumatic mitral stenosis or metal valvar prosthesis (INR > 2.5), (Evidence Level A); (3) oral anticoagulants for patients with two or more of the following risk factors: age ≥ 75 years, HAS, HF, LV ejection fraction = 35% and Diabetes Melitus, (Evidence Level A); (4) acetylsalicylic acid 81mg to 325 mg to replace oral anticoagulants when they are contraindicated (Evidence Level A); and (5) heparin, preferably of low molecular weight, temporarily used during oral anticoagulation with- drawal periods, such as due to surgical procedures (Evidence Level C). 4.2 Thromboembolism prevention in patients scheduled for electrical cardioversion Class I: (1) Oral anticoagulation (INR between 2.0 and 3.0) for three weeks before electrical or pharmacological cardioversion in all patients with AF lasting ≥ 48 hours, or when duration is unknown, (Evidence Level B). Patients with metal valvar prosthesis should maintain INR > 2.5. (2) Fractionated heparin administration (unless contraindicated) with initial bolus injection followed by continuous infusion with adjusted dose to prolong activated partial thromboplastin time (APTT) 1.5 to 2 times the control value in AF lasting 48 hours needing immediate cardioversion due to hemo- dynamic instability. There are still insufficient data to reco- mmend low molecular weight heparin (Evidence Level C). Class IIA: (1) Trans-esophageal ECG to identify atrial and atrial appendix clots as an alternative to anticoagulation Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com