Service de neurologie, Hôpital Sainte-Anne, Paris, France
Atrial fibrillation (AF) is a common and serious condition in the elderly, concerning about 10% of people over 80. AF is a predictive factor for mortality in the elderly and a major risk factor for stroke. Approximately 15% of patients admitted for ischemic stroke have AF and the proportion increases with age, reaching about 40% in people over 80. Compared to patients with stroke unrelated to AF, patients with AF-associated stroke suffer from more severe strokes with an increased risk of remaining disabled after the event and have a higher risk of stroke recurrence. Although most ischemic strokes in AF patients are probably cardioembolic, due to migration of thrombi originating from the left atrial appendage, many elderly patients will be found to have other potential causes of stroke, such as extracranial or intracranial atherosclerotic stenosis, aortic arch atheroma, or small vessel disease. The absolute risk of stroke in patients with AF varies widely depending on associated risk factors, the most important being age over 75 and previous stroke or transient ischemic attack. Several scoring systems have been developed to help clinicians estimate the stroke risk on an individual basis and to guide the choice of the most appropriate preventive therapy. The management of AF in the elderly should involve a detailed evaluation of the patient's functional status and social situation. Specific precautions for treatment must be taken because of the co-morbidities and age-related changes in pharmacokinetics or pharmacodynamics. The benefits of VKAs have been largely shown in patients with AF and appear to be even more important among elderly people. Anticoagulants are recommended in patients with AF aged 75 years or above after assessing the bleeding risk. Novel oral anticoagulants (NOACs) are promising treatments, especially due to a lower risk of intracerebral haemorrhage. However, their prescriptions should take into account renal and cognitive functions.