title: Atrial fibrillation management in older heart failure patients: a complex clinical problem.
abstract: BACKGROUND
  Atrial fibrillation (AF) and heart failure (HF), two problems of growing prevalence as a consequence of the ageing population, are associated with high morbidity, mortality, and healthcare costs. AF and HF also share common risk factors and pathophysiologic processes such as hypertension, diabetes mellitus, ischemic heart disease, and valvular heart disease often occur together. Although elderly patients with both HF and AF are affected by worse symptoms and poorer prognosis, there is a paucity of data on appropriate management of these patients.
  
  
  METHODS
  PubMed was searched for studies on AF and older patients using the terms atrial fibrillation, elderly, heart failure, cognitive impairment, frailty, stroke, and anticoagulants.
  
  
  RESULTS
  The clinical picture of HF patients with AF is complex and heterogeneous with a higher prevalence of frailty, cognitive impairment, and disability. Because of the association of mental and physical impairment to non-administration of oral anticoagulants (OACs), screening for these simple variables in clinical practice may allow better strategies for intervention in this high-risk population. Since novel direct OACs (NOACs) have a more favorable risk-benefit profile, they may be preferable to vitamin K antagonists (VKAs) in many frail elderly patients, especially those at higher risk of falls. Moreover, NOACs are simple to administer and monitor and may be associated with better adherence and safety in patients with cognitive deficits and mobility impairments.
  
  
  CONCLUSIONS
  Large multicenter longitudinal studies are needed to examine the effects of VKAs and NOACs on long-term cognitive function and frailty; future studies should include geriatric conditions.
authors.affiliation: Cardiology1/CCU, San Camillo Hospital, Rome - Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Pulignano
authors.affiliation: Cardiology Unit, Nuovo Regina Margherita Hospital, Rome - Italy.
authors.forename: Donatella
authors.initials: D
authors.lastname: Del Sindaco
authors.affiliation: Cardiology1/CCU, San Camillo Hospital, Rome - Italy.
authors.forename: Maria Denitza
authors.initials: MD
authors.lastname: Tinti
authors.affiliation: Cardiology1/CCU, San Camillo Hospital, Rome - Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Tolone
authors.affiliation: Cardiology1/CCU, San Camillo Hospital, Rome - Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Minardi
authors.affiliation: Cardiology Unit, Nuovo Regina Margherita Hospital, Rome - Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Lax
authors.affiliation: Cardiology1/CCU, San Camillo Hospital, Rome - Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Uguccioni
keywords: Atrial fibrillation; Cognitive impairments; Elderly; Frailty; Heart failure; Oral anticoagulants