Guidance to help upskill primary and secondary care clinicians in decision making when managing atrial fibrillation in frail older people


Ensure you are familiar with the principles outlined in Managing cardiovascular disease in frail older people.

Atrial fibrillation in older people

Atrial fibrillation (AF) is the most common cardiac arrhythmia. Prevalence increases significantly with age with this rising to more than 10% in those over the age of 80 years.

The mortality and morbidity from AF is due to the increased risk of stroke:

  • patients with AF have, on average, a five-fold increase in their risk of a stroke compared to patients in sinus rhythm (the normal heart rhythm) and AF related strokes are associated with increased mortality or higher levels of on-going disability
  • anticoagulation of the appropriate patients is a highly effective intervention, which will reduce an individual’s stroke risk from an AF related stroke by around two-thirds

Assessing the risk of stroke and bleeding

The following information should provide a framework to help with shared decision-making for individual patients on the prescription of anticoagulation, the choice of anticoagulant and the frequency of follow up required.

Provision of written and verbal patient and /or carer information is important to support adherence to treatment and to ensure that any adverse effects are identified and acted upon.

Stroke risk assessment

Clinical data and guidelines support the offer of anticoagulation in older people living with frailty.

A stroke risk assessment should be undertaken using the CHA2DS2VASc score.

If the score is two or more, the patient should be offered anticoagulation (anticoagulation may also be considered in a male patient with a score of 1). As age and female gender feature in the score, it is likely that older people will fulfil the criteria to consider anticoagulation regardless of any co-morbidity.

Bleeding risk assessment

Any offer of anticoagulation should take into account bleeding risk. The use of a scoring system such as HAS-BLED or ORBIT can help to identify modifiable bleeding risk factors.

Bleeding risk factors include:

  • uncontrolled hypertension
  • previous bleeds
  • labile INR in patients taking warfarin
  • alcohol intake
  • co-prescription of other medicines that may increase bleeding risk such as NSAIDs, aspirin or other antiplatelet agents, SSRI antidepressants or oral corticosteroids

The combination of anticoagulation and antiplatelet therapy significantly increases bleeding risk. In many cases, the antiplatelet can be stopped when anticoagulation is introduced so this combination should always be clarified to ensure it is intentional and/or required. Always seek specialist advice if these is any uncertainty of the intended combination or duration of combined therapy.

Falls risk

Risk of falls should not be used as the sole criteria for not offering anticoagulation to a patient although this may be taken into account as part of that overall assessment of suitability and/or frailty.

Rate and rhythm control

Patients with AF may be symptomatic with typical symptoms being:

  • awareness of an irregular heartbeat
  • palpations
  • dizziness or syncope (fainting or blackouts)
  • shortness of breath and chest tightness

However, many patients are asymptomatic and unaware that they have this cardiac arrhythmia.

Rate control strategy

A normal resting heart rate for adults in sinus rhythm is 60-100 beats per minute.  Studies in AF have not shown a benefit of strict heart rate control (less than 80 beats /minute) versus more lenient heart rate control (less than 110 beats/minute).

First line medication

The first choice of medication is usually a beta-blocker.

Alternatively, or in addition, a rate limiting calcium channel blocker (not verapamil + beta-blocker) or digoxin may be added.


In sedentary, frail patients digoxin monotherapy can be a good option as digoxin does not lower blood pressure and can be used in patients with heart failure.

However digoxin has a narrow therapeutic index and needs to be dosed carefully with respect to renal function and electrolyte disturbances such as hypokalaemia, hypomagnesaemia or hypercalcaemia which can be triggered by the use of diuretics or dehydration which can increase digoxin toxicity.

Proactively monitor for signs of digoxin toxicity, which include nausea, vomiting, confusion, anorexia, visual disturbances and depression.

Rhythm control strategy

In frail older people attempting to convert the heart back to its normal rhythm would only be undertaken if the patient was not tolerating the arrhythmia.

First line medication

Medication that may be used includes beta-blockers or anti-arrhythmic medicines such as flecainide, sotalol or amiodarone.

The use of flecainide and sotalol in older people is limited by the presence of heart failure or coronary heart disease (where these medicines are contra-indicated).


Although amiodarone can be a useful drug, long-term use should ideally be avoided because of its adverse drug effect profile. If the patient remains in atrial fibrillation or has been prescribed amiodarone and is no longer under specialist (cardiology) review primary care may need seek advice from the cardiology specialist regarding stopping or continuing treatment.

When to refer

Consider referral to specialist care if symptoms persist or for further advice.

Case study

Atrial fibrillation


A 76-year old man with a new diagnosis of AF.

Past medical history

  • STEMI with stent to the coronary artery 4 years ago
  • Hypertension for 10 years GI bleed 9 months ago
  • Fractured neck of femur following a fall 1 year ago

Questions to think about

  • Would you offer this patient anticoagulation?
  • What factors would you need to consider?
  • How would you discuss this with the patient?
  • Do you have a check list of points to cover when starting a patient on anticoagulation?

Useful resources

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