OPTIMAL MANAGEMENT OF OLDER PATIENTS WITH ATRIAL-FIBRILLATION

Long term oral warfarin should be administered to elderly patients wit h atrial fibrillation who are at high risk for developing thromboembol ic, stroke and who have no contraindications to anticoagulant therapy. Oral aspirin (acetylsalicylic acid) 325 mg daily may be given to elde rly patients with chronic atrial fibrillation who have contraindicatio ns to anticoagulant therapy or who are not at high risk for developing thromboembolic stroke. Management of atrial fibrillation includes tre atment of the underlying disease and precipitating factors. If patient s have paroxysmal atrial fibrillation with a very rapid ventricular ra te associated with hypotension, severe left ventricular failure or che st pain due to myocardial ischaemia, immediate direct-current cardiove rsion should be performed. Intravenous verapamil, diltiazem or a beta- blocker should be used for immediate slowing of a very rapid ventricul ar rate associated with atrial fibrillation. If a rapid ventricular ra te associated with atrial fibrillation persists at rest or during exer cise despite digoxin, then oral verapamil, diltiazem or a beta-blocker should be added. Low dosages of oral amiodarone (200 to 400 mg/day) m ay be used in selected patients with symptomatic life-threatening atri al fibrillation refractory to other therapy. No medication which depre sses atrioventricular conduction should be given to patients with atri al fibrillation and a slow ventricular rate. Cardioversion should not be performed in asymptomatic elderly patients with chronic atrial fibr illation. This author would use a beta-blocker for control of ventricu lar arrhythmias and following conversion of atrial fibrillation to sin us rhythm. Should atrial fibrillation recur, beta-blockers have the ad ditional advantage of slowing the ventricular rate.