In atrial fibrillation, the heart’s atria no longer beat in an orderly fashion but instead beat chaotically at a high rate (300 to 600 beats per minute). The ventricles respond irregularly, and the pulse is erratic. This leads to two main problems:
- Risk of stroke: Blood clots form in the atria, which are no longer pumping properly, and can travel to the brain and cause strokes.
- Heart failure: The chronically irregular and often excessively rapid rhythm strains the heart and can worsen or trigger heart failure in older adults.
Types based on duration:
- Paroxysmal atrial fibrillation: Episodes that stop spontaneously within 7 days
- Persistent atrial fibrillation: Lasting longer than 7 days, but medically reversible
- Permanent atrial fibrillation: Persistent, with no attempt to restore normal rhythm
- Germany: approximately 2 million people with diagnosed atrial fibrillation
- The underreported figure is likely 50 percent higher—many patients have undiagnosed “silent” atrial fibrillation
- Ages 60 to 69: about 4 percent
- Ages 70 to 79: about 9 percent
- Over 80 years old: over 10 percent
The prevalence roughly doubles with each decade of life. This makes atrial fibrillation one of the classic geriatric conditions—closely related to frailty syndrome and frequently occurring alongside heart failure and diabetes in older adults.
In younger patients, atrial fibrillation often presents with noticeable symptoms: palpitations, irregular heartbeats, reduced physical performance, shortness of breath, and dizziness. In older patients, these symptoms are often absent—the atrial fibrillation remains asymptomatic. Possible atypical signs:
- Nonspecific fatigue or exhaustion
- Decreased stamina when walking
- Occasional dizziness
- Mild shortness of breath that is “attributed to old age”
- Worsening of existing heart failure
- Acute stroke as the first manifestation
That is why the pulse is measured during every routine checkup in older adults—sometimes even at the pharmacy or using modern smartwatches, which can now reliably detect atrial fibrillation.
The diagnosis is made through:
- Pulse measurement and auscultation
- Resting ECG—the gold standard for diagnosis when an active rhythm is present
- Long-term ECG (24 hours to 7 days) if paroxysmal atrial fibrillation is suspected
- Event recorders or implantable loop recorders in unclear cases
- Echocardiography — structural heart changes, atrial size, pumping function
- Laboratory: Thyroid function (hyperthyroidism can trigger atrial fibrillation), electrolytes, renal function, complete blood count
For every patient with atrial fibrillation, two independent decisions are made:
Decision 1: Rhythm control or rate control?
- Rhythm control: The goal is to restore normal sinus rhythm—through medication (antiarrhythmic drugs such as flecainide, amiodarone, dronedarone), electrical cardioversion, or catheter ablation.
- Rate control: The goal is not to restore normal rhythm, but to control the heart rate—using beta-blockers, calcium channel blockers, or digitalis.
In older patients with long-standing, asymptomatic atrial fibrillation, rate control is often the simpler and safer approach. In younger or symptomatic patients, rhythm control—including catheter ablation—is an option with good outcomes.
Decision 2: Anticoagulation?
Regardless of the rhythm management decision: The risk of stroke is the same in both cases. Anticoagulation is therefore often the more important decision. It is based on 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 — History of stroke, TIA, or thromboembolism (2 points)
- V — Vascular disease (1 point)
- A — Age 65 to 74 years (1 point)
- Sc — Sex category (female, 1 point, if at least one other risk factor is present)
Oral anticoagulation is recommended for men with a score of 2 or higher and for women with a score of 3 or higher. In practice, this means that nearly every patient over the age of 75 with atrial fibrillation benefits from anticoagulation.
Since the introduction of direct oral anticoagulants (DOACs), standard care has changed:
- Apixaban: Taken twice daily; often preferred for older adults due to a lower risk of bleeding.
- Rivaroxaban: Taken once daily; convenient, but associated with a slightly higher risk of bleeding in some studies.
- Edoxaban: Taken once daily; often used in patients with renal insufficiency.
- Dabigatran: Taken twice daily; a specific antidote is available (idarucizumab).
DOACs have advantages over the traditional vitamin K antagonist phenprocoumon (Marcumar): no need for regular blood tests, fewer food and drug interactions, and a lower risk of cerebral hemorrhage. Marcumar remains in use for specific situations (mechanical heart valves, severe renal insufficiency, certain interactions). In cases of polypharmacy among the elderly, the selection of the appropriate medication must be made with particular care.
The most common reason older patients are not prescribed anticoagulants 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 with DOACs: 2 to 4 percent per year
- Strokes are often more severe than bleeding events—the burden of disability and mortality is significantly greater
- Contrary to popular belief, falls in older adults are—in most cases—not a reason to discontinue anticoagulation. Calculations show that discontinuation can only be considered in patients at extremely high risk of falling who also have a very low risk of stroke
- The HAS-BLED score: helps identify patients at particular risk of bleeding—not to prevent anticoagulation, but to specifically address modifiable risk factors.
???? The key misconception: “He falls, so we can’t use anticoagulation.” The data show that a patient would have to fall more than 300 times a year for the risk of bleeding from falls to exceed the risk of stroke. This is practically impossible. Falls alone are not a reason to discontinue anticoagulation.
→ For a structured fall assessment: Falls in older adults and fall prevention.
For symptomatic atrial fibrillation that does not respond adequately to medication, catheter ablation is an established treatment option. In this procedure, the triggering areas in the atrium (usually around the pulmonary veins) are ablated using heat or cold energy. Ablation is now effective and safe even in older patients in good general health—age alone is not a contraindication. The evaluation of general health should include a geriatric assessment.
For older patients with atrial fibrillation, decision-making is more complex than for younger patients. The key lies in individualization:
- What comorbidities are present? What is the patient’s renal function?
- What medications are they already taking? What potential drug interactions exist?
- What is the patient’s cognitive status? Can the patient safely take their medications?
- What is the risk of falls and fractures?
- What are the patient’s quality of life and treatment goals?
- Who is helping with medication adherence?
Geriatrics provides the holistic perspective needed to address these questions—a perspective that individual organ-specific specialties often cannot provide. Collaboration with cardiology and the primary care physician is crucial in this regard.
→ For medication management in cases of polypharmacy in older adults and structured deprescribing.
→ For a broader context: Geriatric assessment.
- Check the pulse regularly on their own: on the wrist, for 30 seconds. An irregular pulse lasting several minutes is a reason to see the primary care physician.
- Do not stop anticoagulation therapy lightly: Not even before minor procedures such as dental treatments. Always consult with the doctor.
- Be aware of warning signs of bleeding: blood in the urine or stool, nosebleeds, unexplained bruising, headaches after a fall.
- If a fall involves a head injury: Call an ambulance—even if there are no visible injuries. Brain hemorrhages can occur with a delay while on anticoagulants.
- Mention this to your dentist or specialist: The fact that you are taking anticoagulants is relevant for any medical procedure.
- If you experience a new irregular pulse
- Heart palpitations, shortness of breath, decreased stamina, dizziness—even if only occasional
- If you have a known history of atrial fibrillation and are unsure about your current treatment
- After a new fall in older adults and questions about whether anticoagulation should be paused (the answer is almost always “no”)
- In cases of severe bleeding
- Before planned major surgeries
- When considering ablation or rhythm therapy
