Invasive management of atrial fibrillation and the elderly

Invasive management for symptomatic AF in the elderly is an important consideration to potentially improve quality of life. When the primary caregiver needs to counsel an elderly patient with AF on appropriate management strategies, the following steps should be undertaken: 1. Determine the appropriate choice for anticoagulation. 2. An attempt at rate control to alleviate symptoms. 3. Consider rhythm control strategy with a pharmacological agent when patients remain symptomatic despite rate control. 4. Consider AV node ablation if rate control is not possible pharmacologically or is associated with intolerable side effects. 5. For those patients who remain symptomatic despite the above measures, AF ablation should be considered along with possible adjunctive pacemaker-based therapy. Elderly patients should not be excluded from invasive therapy, as with appropriate caution these procedures can be performed with acceptable risk and a relatively high chance of alleviating symptoms. Patients, however, should be made aware that ablation is being offered purely for symptom-relief since there is no evidence to support invasive therapy purely to decrease mortality or to decrease stroke risk.