In the last twelve years the clinical management of patients with atrial fibrillation has been revolutionised by the introduction of direct oral anticoagulants. Despite the large amount of evidence produced, some populations remain relatively poorly explored regarding the effectiveness and safety of direct oral anticoagulants, such as the oldest and/or frailest individuals. Frailty is clinical syndrome characterized by a reduction of functions and physiological reserves which results in individuals having higher vulnerability. While current evidence underlines a relationship between atrial fibrillation and frailty, particularly in determining a higher risk of adverse outcomes, data regarding effectiveness and safety of direct oral anticoagulants in frailty atrial fibrillation patients are still lacking, leaving uncertainty about how to guide prescription in this specific subgroup. On these premises, this multidisciplinary consensus document explains why it would be useful to integrate the clinical evaluation performed through comprehensive geriatric assessment to gather further elements to guide prescription of direct oral anticoagulants in such a high-risk group of patients.

Atrial fibrillation (AF) is a relevant cardiovascular condition that is more prevalent in the elderly patients aged over 65 years. AF, with abnormal rate and rhythm can cause symptoms directly or indirectly by exacerbating other frequently coexisting cardiac conditions such as valvular heart disease, hypertension, ischemic cardiomyopathy, dilated cardiomyopathy, and hypertrophic cardiomyopathy. Evidence suggests that aging-related cardiovascular changes predispose the elderly to AF. Current therapeutic options such as antiarrhythmic drugs have not been extensively evaluated in the elderly population. Emerging pharmacological and non-pharmacological treatment options for the management of AF, such as dronedarone or catheter ablation, are of particular interest in the elderly. The present paper reviews the pathophysiology, diagnosis, and the management of AF in the elderly patient.