Atrial fibrillation in the elderly -- not a benign condition

Atrial fibrillation (AF) is the most commonly seen arrhythmia and its prevalence increases with age. In the general population, rates of 1-2% are reported but in older patients, the rates increase to over 10% (in those aged 85years or older). Many older patients present to the emergency department (ED) with complaints that could be caused or associated with AF including valvular heart disease, hypertension, heart failure, an underlying infection (urinary or chest) and thyroid disorder. The most devastating complication of AF is stroke and early detection of AF and initiation of treatment (specifically the use of anti-coagulant medication) can significantly reduce the risk. AF is associated with high healthcare costs and has significant impacts on disability and quality of life especially if a stroke occurs. This review aims to describe the aetiology and treatment options for patients with newly diagnosed and previously diagnosed AF with an emphasis on how ED staff can manage older patients with AF and ensure optimal care is given. The treatment of AF has three main considerations (i) appropriateness for thromboembolic prophylaxis, (ii) rate control (including anti-arrhythmics, cardiac glycosides, B blockers and calcium channel blockers) and (iii) rhythm control with traditional cardioversion (either electrically or pharmacologically) or utilising interventional means to maintain sinus rhythm with cardiac surgery and more recently radio-frequency ablation. As anti-coagulation is widely implemented, the risks and benefits associated with warfarin and the newer agents will be described. Given that more than half of those with AF are over 75years and 30% of AF is diagnosed incidentally, there is an imperative for prompt diagnosis to reduce the risk of debilitating complications especially stroke. AF should not be viewed as yet another concomitant "benign" condition. Emergency staff are well placed to detect AF and ensure appropriate treatment is commenced to reduce the adverse events associated with it.