Frailty- and Age-Informed Management of Atrial Fibrillation in Older Adults: Anticoagulation, Rhythm Control, and Comorbidity Care

Atrial fibrillation (AF) in older adults extends well beyond stroke prevention. Advancing age is the strongest demographic driver of AF prevalence and adverse outcomes, and it frequently coexists with frailty - a multidimensional syndrome characterized by reduced physiological reserve and heightened vulnerability to adverse events. Together, age and frailty shape the risk–benefit profile of every AF treatment decision, including anticoagulation, rate and rhythm control, and comorbidity management, yet they remain inconsistently recognized in clinical trials and routine practice. Traditional approaches often overlook age-specific physiological changes and geriatric considerations, contributing to an evidence–practice gap. Competing risks of thromboembolism and bleeding, cognitive impairment, polypharmacy, multimorbidity, and fluctuating functional status make holistic AF management in this population both essential and challenging.Recent studies have highlighted the consequences of suboptimal AF care in older and frail patients, including increased rates of stroke, major bleeding, hospitalization, functional decline, loss of independence, and diminished quality of life. Emerging evidence supports incorporating validated frailty and geriatric screening into cardiovascular care and adapting modern risk prediction tools - integrating clinical risk factors with measures of age, frailty, and functional status - to better stratify risk and guide shared decision-making across all pillars of AF management. Individualized anticoagulation with direct oral anticoagulants (DOACs) requires careful attention to renal function, comorbidity profiles, drug interactions, and patient preferences. In parallel, decisions about rate versus rhythm control - including antiarrhythmic drugs, catheter ablation, cardioversion, pacing strategies, and left atrial appendage occlusion - are increasingly relevant in older and frail patients, as is the integrated management of comorbidities and modifiable risk factors. Despite these advances, a critical need remains for research defining best practices for age- and frailty-informed AF care across diverse healthcare systems.This Research Topic aims to advance age- and frailty-informed AF management across the full continuum of care for older adults. Key objectives include: detailing approaches to frailty identification and risk stratification in geriatric AF populations; examining associations between age, frailty, stroke, bleeding, and arrhythmia-related outcomes; assessing the safety and effectiveness of individualized anticoagulation, rate-control, and rhythm-control strategies (including catheter ablation and device-based therapies) in older and very old adults; evaluating integrated management of cardiovascular and non-cardiovascular comorbidities; and testing interventions such as multidisciplinary geriatric–cardiology care models, deprescribing protocols, and technology-enabled decision-support tools.The scope encompasses but is not limited to: (1) frailty and geriatric screening methods in older AF patients; (2) integration of age and frailty into risk prediction models for stroke, bleeding, and arrhythmia outcomes; (3) real-world selection, dosing, and monitoring of anticoagulants in older and frail populations; (4) rhythm-control strategies, including antiarrhythmic drug selection, catheter ablation, cardioversion, and hybrid approaches; (5) rate-control optimization, pacing strategies, and left atrial appendage occlusion; (6) integrated management of comorbidities (heart failure, chronic kidney disease, diabetes, hypertension, sleep-disordered breathing, cognitive impairment) and modifiable risk factors (weight, alcohol, physical activity); (7) bleeding-mitigation, polypharmacy review, and deprescribing strategies; and (8) outcomes related to stroke, bleeding, hospitalization, function, and quality of life in geriatric AF cohorts. Contributions addressing care variation, health system factors, and patient-centered perspectives are strongly encouraged. By supporting interdisciplinary investigation across cardiology, geriatrics, primary care, and allied health, this Topic aims to generate actionable insights and improve care for older adults living with AF. Topic editors: Paolo Muratori, Elisa Fabbri Source: https://www.frontiersin.org/research-topics/80794/frailty--and-age-informed-management-of-atrial-fibrillation-in-older-adults-anticoagulation-rhythm-control-and-comorbidity-care