Franken RA et al. Atrial fibrillation in the elderly Realization that between 65–74 years of age is worth one point, and an age above 75 years is worth two points, places this isolated factor as a risk for thromboembolic complications. According to these criteria, patients with zero points do not need anticoagulation or anti-thrombotic drugs; patients with 1 point receive aspirin or warfarin; and patients with 2 or more points should receive warfarin with controlled dosage according to an International Normalized Ratio (INR) of between 2 and 3. Patients who cannot take warfarin should receive double anti-thrombotic therapy with aspirin and clopidogel, which in the ACTIVE A study has better protected patients than aspirin alone[26,27] The recommended aspirin dose is controversial and studies have administered it between 81 mg and 325 mg per day. AF is also related to cognitive disorders and vascular dementia. In the Rotterdam Study,[28] the risk of dementia was twice as high for fibrillating elderly. Elderly people with AF had memory and dementia disorders unrelated to stroke.[29,30] This is probably due to cardioembolic events and low cardiac output. AF in the elderly may be asymptomatic as a casual finding in routine clinical evaluation or electrocardiogram (ECG). In symptomatic patients, arrhythmic palpitation is a frequent complaint and may occur with syncope, angina, acute lung edema and/or systemic embolim. In general, cerebral or pulmonary and even symptomatic patients during AF episodes, do not notice their arrhythmia in more than half of the episodes during Holter analysis,[31,32] thus making it difficult to clinically evaluate the presence and frequency of AF episodes. Asymptomatic arrhythmia does not mean lower risk of thromboembolic episodes and, very often, arrhythmia is diagnosed during or after stroke or transient ischemic attack. Symptomatic paroxistic AF patients present also transient asymptomatic arrhythmia episodes leading to the discussion if anti-arrhythmic drugs used to prevent recurrence actually turn the episodes into asymp- tomatic.[33] Asymptomatic episodes bring to the discussion of the need for anticoagulation in patients with acute AF reverted to sinus rhythm and for how long this should be maintained. Final arrhythmia diagnosis is achieved with ECG, as described in the first AF characterization via ECG made by Eintowen in 1906. 2 Atrial flutter Described in the early 20th Century, atrial flutter, in general, is symptomatic with palpitation. Atrial flutter is less tolerated than AF, frequently causing angina pectoris, HF and hypotension, depending on ventricular rate and function. 93 The risks of thromboembolic events during atrial flutter have not been well studied, but should not be overlooked.[34] 3 AF prevention Considering the high AF morbidity and mortality, arrhythmia should be prevented. The disease most often associated to AF is hypertension, followed by HF and coronary disease.[35] Measures to prevent or treat such diseases prevent their evolution to AF. Another well-individualized factor is obesity. Obese people have increased left atrium size, especially when associated with any of the above-described diseases.[36] Weight loss is followed by left atrium size decrease.[37] Frequently we do not find a cause for AF, but lately genotypes predisposing to arrhythmia have been described.[38–40] 4 Treatment AF treatment has three objectives: (1) relieve symptoms; (2) prevent HF; and (3) prevent thromboembolism. The methods of treatments are: (1) sinus rhythm reversion through chemical or electrical cardioversion; (2) prevention of recurrences; and (3) in cases of sinus rhythm re-establishment failure, the control of ventricular response associated to chronic anticoagulation must be applied. It is important to stress that the most effective AF therapy, definitively proven by controlled and statistically adequate studies, is anticoagu- lation to prevent thromboembolism, before or after cardio- version and for patients elected for ventricular response control. If for any reason patients cannot receive anticoagulants, antiplatelet agents are the alternative. Oral antiplatelet and anticoagulant drugs with adjusted dosage, as compared to placebo, have their efficacy proven to prevent AF embolic events in several meta-analysis trials since the 1980’s. The risk reduction for primary prevention was 2.7% per year and for secondary prevention 8.4% per year.[41,42] The AFFIRM study teaches us that anticoagulation withdrawal in rhythm control trial arms has increased the incidence of thromo- boembolic accidents, even in asymptomatic patients in sinus rhythm.[43,44] Thromboembolic risk is the same for paroxysmal, persistent or permanent AF,[45] therefore AF patients should be anticoagulated in all situations. When using warfarin, patients must be closely followed due to hemorrhagic complications which to be prevented, require sequential control of prothrombin activity and INR. Regular dietary habits are recommended due to the interaction of warfarin with dark green leafed vegetables. The interact- tion of warfarin with other drugs may also be considered http://www.jgc301.com; jgc@mail.sciencep.com | Journal of Geriatric Cardiology