Journal of Geriatric Cardiology (2012) 9: 91−100 ©2012 JGC All rights reserved; www.jgc301.com Symposium: Contributions from Department of Geriatric Cardiology of the Brazilian Society of Cardiology Guest Editors: Jose C. Nicolau, Claudia F Gravina and Roberto A. Franken Atrial fibrillation in the elderly • Open Access • Roberto A. Franken1, Ronaldo F. Rosa1, Silvio CM Santos2 1Department of Internal Medicine, Santa Casa São Paulo Medical School, R.Dr.Franco da Rocha 163/52, São Paulo 05015-040, Brazil 2Brazilian Society of Cardiology, Rua Padre bartolomeu Tadei 18, Santos 11035-150, Brazil Abstract This review discusses atrial fibrillation according to the guidelines of Brazilian Society of Cardiac Arrhythmias and the Brazilian Cardiogeriatrics Guidelines. We stress the thromboembolic burden of atrial fibrillation and discuss how to prevent it as well as the best way to conduct cases of atrial fibrillatios in the elderly, reverting the arrhythmia to sinus rhythm, or the option of heart rate control. The new methods to treat atrial fibrillation, such as radiofrequency ablation, new oral direct thrombin inhibitors and Xa factor inhibitors, as well as new antiarrhythmic drugs, are depicted. J Geriatr Cardiol 2012; 9: 91−100. doi: 10.3724/SP.J.1263.2011.12293 Keywords: Atrial fibrillation; Heart failure; Thrombo-embolism; Treatment; Prevention 1 Atrial fibrillation Atrial fibrillation (AF) was known long before it was characterized in animals by William Harvey in 1628 in the De Motu Cordis text.[1] Arrhythmia was undervalued until approximately 30 years ago; and currently it is a major predictor of cardiovascular events, especially in the elderly. AF-related phenotypes are being detected today.[2] Presently, several misinterpretations involve arrhythmia, especially in the elderly, such as: (1) AF is a benign arrhythmia; (2) Chemical reversion is less risky than electrical reversion; (3) Anticoagulation in the elderly is of high risk, so one should prefer antiplatelet agents; and (4) Sinus rhythm reversion eliminates anticoagulation maintenance. These inaccurate statements increase morbidity and mortality associated with arrhythmia and lead to what we call omission iatrogeny. From the electrophysiological point of view, AF is characterized by the loss of electrical atrial homogeneity due to isolated or associated autonomic, metabolic, structural, inflammatory, or ischemic defects AF is the most prevalent chronic arrhythmia in patients above 65 years old (5.9% of the population), and its prevalence from 50 years old on, doubles every 10 years,[3] Correspondence to: Roberto A. Franken, Professor, Department of Internal Medicine, Santa Casa São Paulo Medical School, R.Dr.Franco da Rocha 163/52, São Paulo 05015-040, Brazil. E-mail: frankenr@terra.com.br Telephone: +55-11-99978820 Fax: +55-11- 32584777 Received: December 29, 2011 Revised: April 20, 2012 Accepted: April 27, 2012 Published online: June 1, 2012 http://www.jgc301.com; jgc@jgc301.com | Journal of Geriatric Cardiology being more common in male. In the ATRIA study, the prevalence was 0.1%, in females below 55 years of age, while in those above 85 years old, it was 9.1%; for males, figures were 0.2% and 11.0%, respectively.[4] The Western study has identified factors related to AF. First, it has identified patient’s age and then hypertension, diabetes, heart failure and valve disease.[5] In the Asian population, the described factors were: age above 80 years, history of heart disease, diminished glomerular filtration rate and hypercholesterolemia.[6] International guidelines[7] have classified AF as: (1) AF detected for the first time (symptomatic or not, self-limited, or of unknown duration, or when the presence of previous episodes is unknown, being paroxysmal or persistent); (2) paroxysmal is characterized by recurrent episodes and spon- taneous reversion; (3) persistent or lasting more than seven days and needing chemical or electrical cardioversion to re-establish the sinus rhythm; and (4) permanent or lasting more than one year, and refractory to cardioversion. The classification is only used in situations where there is no reversible AF cause, such as acute myocardial infarction, pulmonary embolism, hyperthyroidism, alcoholism, etc.[8,9] AF is generally associated to structural heart disease, however, it may occur in patients without detectable heart disease called isolated AF. The term should not be applied to the elderly because co-morbidities are common at this age and may contribute to arrhythmia chronicity.[10] Historically, the first arrhythmia cause was identified as rheumatic valve disease, however with population aging and