In atrial fibrillation the atria of the heart no longer beat in an orderly way but chaotically at a high frequency (300 to 600 per minute). The ventricles respond irregularly, the pulse is arrhythmic. Two main problems arise:
- Risk of stroke: In the atria, which no longer pump properly, blood clots form that can migrate to the brain and trigger strokes.
- Heart failure: The chronically irregular and often too rapid rhythm strains the heart and can worsen or trigger heart failure in old age.
Forms according to temporal course:
- Paroxysmal atrial fibrillation: episodes that stop spontaneously within 7 days
- Persistent atrial fibrillation: lasting longer than 7 days, but medically convertible
- Permanent atrial fibrillation: permanently present, no restoration of rhythm aimed for
- Germany: around 2 million people with known atrial fibrillation
- Number of unreported cases probably 50 percent higher — many patients have unrecognised silent atrial fibrillation
- 60 to 69 years: about 4 percent
- 70 to 79 years: about 9 percent
- Over 80 years: over 10 percent
The prevalence roughly doubles per decade of life. This makes atrial fibrillation one of the classic geriatric conditions — closely related to the frailty syndrome and frequently occurring together with heart failure and diabetes in old age.
In younger patients atrial fibrillation often makes itself felt: palpitations, heart stumbling, reduced performance, shortness of breath, dizziness. In older patients these symptoms are frequently absent — the atrial fibrillation remains silent. Possible atypical signs:
- Non-specific tiredness or fatigue
- Loss of performance when walking
- Occasional dizziness
- Mild shortness of breath that is “attributed to age”
- Worsening of an existing heart failure
- Acute stroke as the first manifestation
That is why the pulse is measured at every routine examination in old age — sometimes also at the pharmacy or with modern smartwatches, which can now reliably detect atrial fibrillation.
The diagnosis is made via:
- Pulse measurement and auscultation
- Resting ECG — the gold standard for diagnosis when the rhythm is actively present
- Long-term ECG (24 hours to 7 days) when paroxysmal fibrillation is suspected
- Event recorder or implantable loop recorder in unclear situations
- Echocardiography — structural cardiac changes, atrial size, pumping function
- Laboratory: thyroid function (overactivity can trigger atrial fibrillation), electrolytes, kidney function, blood count
In every patient with atrial fibrillation, two independent decisions are made:
Decision 1: Rhythm or rate control?
- Rhythm control: The aim is to restore the normal sinus rhythm — through medications (antiarrhythmics such as flecainide, amiodarone, dronedarone), electrical cardioversion or catheter ablation.
- Rate control: The aim is not to restore the normal rhythm, but to control the heart rate — through beta-blockers, calcium channel blockers or digitalis.
In older patients with long-standing, asymptomatic atrial fibrillation, rate control is frequently the simpler and safer route. In younger or symptomatic patients, rhythm control — up to and including catheter ablation — is an option with good results.
Decision 2: Anticoagulation?
Regardless of the rhythm decision: the risk of stroke is the same in both cases. Anticoagulation is therefore often the more important decision. It follows the CHA2DS2-VASc score:
- C — Chronic heart failure (1 point)
- H — Hypertension (1 point)
- A2 — Age ≥ 75 years (2 points)
- D — Diabetes mellitus (1 point)
- S2 — Stroke, TIA or thromboembolism in the history (2 points)
- V — Vascular disease (1 point)
- A — Age 65 to 74 years (1 point)
- Sc — Sex category (female, 1 point, with at least one further risk factor)
From 2 points in men and from 3 points in women, oral anticoagulation is recommended. In practical terms this means: almost every female and male patient over 75 with atrial fibrillation benefits from anticoagulation.
Since the introduction of the direct oral anticoagulants (DOACs), standard care has changed:
- Apixaban: Taken twice daily, often preferred in older people because of its lower bleeding risk.
- Rivaroxaban: Taken once daily, convenient, but a somewhat higher bleeding risk in some studies.
- Edoxaban: Once daily, often used in renal insufficiency.
- Dabigatran: Twice daily, a specific antidote available (idarucizumab).
DOACs have advantages over the classic vitamin K antagonist phenprocoumon (Marcumar): no regular blood value monitoring required, fewer food and drug interactions, lower risk of cerebral hemorrhage. Marcumar remains in use for certain situations (mechanical heart valves, severe renal insufficiency, certain interactions). In polypharmacy in old age the selection of the right substance must be made with particular care.
The most common reason why older patients are not anticoagulated is the fear of bleeding. This fear is understandable — and in most cases disproportionate. The data:
- Absolute risk of stroke without anticoagulation in older patients with atrial fibrillation: 5 to 10 percent per year
- Absolute risk of major bleeding under DOAC: 2 to 4 percent per year
- The strokes are frequently more severe than the bleeds — the burden of disability and mortality is considerably greater
- Falls in old age are — contrary to the widespread assumption — in most cases not a reason to discontinue anticoagulation. The calculation shows: only in extremely fall-prone patients with a very low risk of stroke can withholding it be considered
- The HAS-BLED score: helps to identify patients with a particular bleeding risk — not in order to prevent anticoagulation, but in order to address modifiable factors specifically.
???? The central misconception: “He falls, so we cannot anticoagulate.” The data show: a patient would have to fall more than 300 times per year for the bleeding risk from falls to exceed the risk of stroke. This is practically unachievable. Falls alone are no reason to forgo anticoagulation.
→ On the structured work-up of falls: Falls in old age and Fall prevention.
In symptomatic atrial fibrillation that does not respond sufficiently to medication, catheter ablation is an established option. The triggering areas in the atrium (usually around the pulmonary veins) are obliterated using heat or cold energy. Even in older patients in good overall condition, ablation is now effective and safe — age alone is not a contraindication. The assessment of overall condition should include a geriatric assessment.
In older patients with atrial fibrillation, decision-making is more complex than in younger ones. The art lies in individualization:
- Which comorbidities are present? How is kidney function?
- Which medications are already being taken? Which interactions are looming?
- What is the cognitive situation? Can the patient reliably manage taking the medication?
- What fall and fracture risk is present?
- What are the quality of life and treatment goals?
- Who supports medication adherence?
In these questions geriatrics brings the overall view that individual organ specialties often cannot provide. Cooperation with cardiology and the general practitioner is decisive here.
→ On medication coordination in polypharmacy in old age and structured deprescribing.
→ For the overarching classification: Geriatric assessment.
- Check the pulse yourself regularly: At the wrist, 30 seconds. An irregular pulse over several minutes: a reason to present to the general practitioner.
- Do not casually pause the anticoagulation: Not even before minor procedures such as dental treatments. Always coordinate with the doctor.
- Know the warning signs of bleeding: Blood in the urine or stool, nosebleeds, bruises without cause, headache after a fall.
- In the case of a fall with impact to the head: Emergency doctor — even without a visible injury. Cerebral haemorrhages under anticoagulation can occur with a delay.
- Mention it at the dentist or specialist: That anticoagulation is being taken is relevant for every medical measure.
- In the case of a newly occurring irregular pulse
- Palpitations, shortness of breath, reduced performance, dizziness — even if only episodic
- With known atrial fibrillation and uncertainty about the current therapy
- After newly occurring falls in old age and the question of whether anticoagulation should be paused (the answer almost always: no)
- In the case of severe bleeding
- Before planned major operations
- In the case of a question about ablation or rhythm therapy
