Vitamin K antagonists especially warfarin was the only oral anticoagulant agent available since the 1950s till recently. With the introduction of direct thrombin inhibitors and factor Xa inhibitors, the options are now open to more convenient and flexible anticoagulation regimens. The most studied non-vitamin K-dependent anticoagulants (NOACs) are dabigatran, rivaroxaban, apixaban, and edoxaban.

Warfarin has been used effectively in elderly patients for many decades. However, the major difficulties in managing warfarin in elderly patients are its interaction with food, drugs, alcohol, liver function, age-related variations, and genetic variations. Periodic monitoring of international normalized ratio (INR) and frequent dosage adjustments are required to ensure protection from thromboembolism and prevention of bleeding complications in patients treated with warfarin. The clinical benefits and risks of anticoagulation therapy with warfarin are directly related to the proportion of time that INR values are between 2 and 3, which is designated as time in therapeutic range (TTR) 21. It has been shown that TTR on warfarin is suboptimal, only 59% in ORBIT-AF study analyzing 5210 patients [18].

Another obstacle encountered in warfarin-based anticoagulation is compliance and discontinuation rates. Discontinuation of warfarin therapy has been alarmingly high 25–50% [19, 20].

The use of NOACs circumvents some of these inconveniences of warfarin. NOACs are in clinical use since 2008 and offer similar or better efficacy, safety, convenience, and freedom from frequent laboratory monitoring. There is no age-related dose adjustment for NOACs. Dose adjustments are required for patients with renal dysfunction. NOACs are not recommended for patients with end-stage renal disease on hemodialysis and in patients with mechanical heart valves [9, 10, 21, 22].

When selecting a specific anticoagulant, patient preference, renal function, and cost should be considered.

Five major prospective randomized trials (PAF2, STAF, PIAF, RACE, and AFFIRM) compared rate control strategy with that of rhythm control, and all of these trials have had similar results [23–27]. Most of the subjects enrolled in the trials were elderly as a reflection of the epidemiology of AF. These studies have shown no advantage of rhythm control strategy over that of rate control. A prespecified subgroup analysis of AFFIRM [27] revealed that rhythm control strategy was associated with higher mortality than rate control. There were no significant differences in functional capacity or cognitive status with either management strategies [28, 29]. Rhythm control strategy is more costly and consumed more resources compared to rate control strategy [30].

In septuagenarians, rate control when compared with rhythm control was associated with lower mortality and hospitalizations [31]. Based on the evidence, rate control is the preferred mode of management on AF in elderly. However rhythm control may be appropriate in certain circumstances such as highly symptomatic patients despite rate control, exercise intolerance, and personal preference.

The three major approaches for rhythm control in atrial fibrillation are antiarrhythmic drugs, cardioversion which could be chemical or electric, and catheter ablation.

Cardioversion can be safely performed without anticoagulation if the duration of AF is less than 48 h and if there is no risk of stroke. If the duration of AF is more than 48 h, anticoagulation with warfarin (to maintain INR between 2 and 3) or NOACs should be done for at least 3 weeks prior to and 4 weeks after cardioversion. Transesophageal echocardiogram (TEE) can be used to rule out the presence of left atrial/LA appendage thrombus to perform cardioversion acutely if duration of AF of more than 48 h and waiting for 3 weeks on anticoagulation is deemed inappropriate [32]. Cardioversion can be achieved by direct current shock or with the use of antiarrhythmic drugs. Among drugs, flecainide, propafenone, dofetilide, or intravenous ibutilide are considered class 1 of recommendation and amiodarone class II a recommendation for cardioversion of AF.

The decision about continuation of long-term anticoagulation depends on the stroke risk assessed by CHA2DS2-VASC score. AAD is moderately effective in maintaining sinus rhythm in long term after cardioversion; however, the long-term risk benefit of these drugs remains unclear. Among the antiarrhythmic drugs, amiodarone is found to be most effective for maintenance of sinus rhythm with less mortality risk than class 1 drugs, and the choice of AAD depends also on comorbidities of the patient and the presence of underlying structural heart disease [33]. Class 1 drugs should be used with extreme caution in patients with structural heart disease because of the risk of pro-arrhythmia. Regular monitoring of QT interval is recommended in patients on class 3 drugs like sotalol or amiodarone.

Most of the symptoms in AF is related to tachycardia, and rate control is an attractive and cost-effective strategy in improving the quality of life of AF patients. Rate control can be achieved by AV nodal blocking medications or by AV node ablation and implantation of permanent pacemaker. The common drugs used for ventricular rate control are (1) beta-adrenergic blockers, (2) non-dihydropyridine calcium channel blockers, and (3) digitalis. Both beta-blockers and calcium channel blockers are equally effective in rate control in atrial fibrillation. Digoxin is a lesser preferred drug as a first-line rate control medications except in-patient with systolic heart failure. The mechanism of action of digoxin is by enhancement of vagal tone on AV node and useful for rate control at rest. Because of the vagal withdrawal associated with exertion, digoxin is not a very useful drug for exercise related tachycardia, which is fairly common in atrial fibrillation. A narrow therapeutic window, interaction with other cardiac drugs and warfarin, and propensity for toxicity with declining renal function on elderly make digoxin a less favorable drug in management of atrial fibrillation.

Another important consideration is about the target heart rates while attempting rate control. A more lenient rate control (resting heart rate < 110 bpm) is found non-inferior to more strict rate control of resting heart rate < 80 bpm and heart rate < 110 with exercise in a randomized controlled trial of permanent AF in patients [34]. Another study compared three strategies of rate control and found no difference in clinical outcomes [35].

Guidelines recommend a stricter rate control of resting heart rate < 80 bpm in symptomatic cases (class IIa). For asymptomatic patients with preserved LV function, a more lenient rate control (<110 bpm) is reasonable (class IIb) to prevent tachycardiomyopathy.