94 and evaluated, as well as different individual responses to anticoagulation treatment related to P450 cytochrome activity. INR should be maintained between the 2 and 3 interval, where the most protective benefits against thromboembolism and lowest hemorrhagic risk are found.[46] Acording to Go et al.[47] using CHADS 2 risk stratifica- tion score, the stroke risk level per 100 person/years is lower using warfarin (Table 2). The ATRIA study and the Euro Heart Survey have reported variables to characterize hemorrhagic risk in patients under warfarin as anemia, renal disease, age > 75 years, previous bleeding, hypertension (Table 3).[48,49] New oral drug therapies, such as direct thrombin inhibitors, dabigatran, and Xa factor inhibitors, such as apixaban, would have, as an advantage, a lower risk profile with no need for periodic control as in the case with warfarin use.[50,51] In spite of evidence and recommendations for their use, anticoagulants are underutilized especially in the elderly above 80 years of age and in patients with malignant solid tumors.[52] Table 2. Chads 2 score stroke risk per 100 person years/on or off warfarin.[47] 0.25 on warfarin; 0.49 no 0.72 on warfarin; 1.52 no 1.27 on warfarin; 2.50 no 2.20 on warfarin; 5.27 no 2.35 on warfarin; 6.02 no 4.60 on warfarin; 6.88 no 0 Points: 1 Point: 2 Points: 3 Points: 4 Points: 5–6 Points: Table 3. score.[48] Hemorrhagic risk is evaluated by the HAS-BLED Letter Clinical characteristic Points awarded H Hypertension 1 A (A1bpnooirnmt aelacrehn)al and liverfunction 1 S Stroke 1 B Bleeding 1 L Labile INRs 1 E Elderly (age > 65 years) 1 D Drugs or alcohol (1 point each) 1 Maximum score is 9. Hypertension is defined as systolic blood pressure ≥ 160 mmHg. Abnormal kidney function is defined as the presence of chronic dialysis or renal transplantation or serum creatinine ≥ 200 mmol/L. Abnormal liver function is defined as chronic hepatic disease (e.g., cirrhosis) or biochemical evidence of significant hepatic derangement (e.g., bilirubin, 2 × upper limit of normal, in association with aspartate aminotransferase/alanine aminotransferase/alkaline phosphatase, 3 × upper limit normal, etc.). Bleeding refers to previous bleeding history and/or predisposition to bleeding, e.g., bleeding diathesis, anemia, etc. Labile INRs refers to unstable/high INRs or poor time in therapeutic range (e.g., 60%). Drugs/alcohol use refers to concomitant use of drugs, such as antiplatelet agents, non-steroidal anti- inflammatory drugs, or alcohol abuse, etc. INR: ¼ international normalized ratio. Franken RA et al. Atrial fibrillation in the elderly The decision for cardioversion to sinus rhythm, or just controlling ventricular response, should be individually esta- blished, taking into account the clinical presentation (paro- xystic permanent or persistent), the presence of symptoms, cardioversion risks and the probability of success of main- taining the sinus rhythm after cardioversion, and the willingness of patients to be treated. One should stress that age is not one isolated factor for electric cardioversion failure (Figures 1 and 2). The expectation with cardioversion, in addition to avoiding the use of anticoagulants, was that reversion to sinus rhythm would be advantageous; decreasing symptoms and increasing exercise capacity, decreasing thromboembolic risk and possibly decreasing mortality.[53] Controlled studies have not shown advantages of any approach, at least with regard to survival.[54] The reference study reaching this conclusion was the AFFIRM study,[55] which included more than 4000 patients. However, a most recent analysis of this study has shown that patients in sinus rhythm in any of the arms had better survival rate, indicating that AF is a mortality risk marker. Antiarrhythmic drugs and digitalis increased the risk of death.[56] Reversion to sinus rhythm may be achieved with drugs or electrical cardioversion. In cases of AF lasting less than 48 hours, previous anticoagulation is not needed, however, when AF lasts longer, or its duration is unknown, patients should be previously anticoagulated for at least 30 days. Chemical reversion may be achieved with intravenous amio- darone, intravenous or oral propafenone. Propafenone should not be used in patients with ventricular disease (Figure 2 ). It is clear today that anticoagulants should be maintained even after reversion to sinus rhythm (Figure 3).[57] After reversion to sinus rhythm, its maintenance requires the use of antiarrhythmic drugs, (Figure 3). The drugs of choice are those of the IC group (propafenone) and III group (amiodarone, sotalol) from the Vaughn-Williams classification. For patients with structurally normal hearts, propafenone or Figure 1. Choice of rate or rhythm control strategies. Direct current conversion and pharmacological cardioversion of recent- onset Atral Fibrilation in patients considered for pharmacological cardioversion Journal of Geriatric Cardiology | jgc@jgc301.com; http://www.jgc301.com