Frailty and advanced age in atrial fibrillation: Implications for treatment strategies and clinical outcomes – A systematic review

BACKGROUND: Atrial fibrillation (AF) is common among frail older adults and poses complex management challenges due to reduced physiological reserve and heightened vulnerability to adverse outcomes. AIMS: This systematic review (2015-2025) examined influence of frailty and advanced age on AF management and outcomes, focusing on anticoagulation, interventional therapies and quality of life. METHODS: Eligible cohort studies, trials, meta-analyses assessed outcomes including mortality, stroke, major bleeding, functional decline, recurrence, healthcare costs and quality of life with frailty measured using validated tools like Clinical Frailty Scale. RESULTS: Frail patients had a two-to threefold higher mortality risk and 40-50% greater incidence of stroke and major bleeding than non-frail peers. Low-dose NOACs reduced stroke in frail octogenarians but bleeding risk persisted. Rate control therapy improved symptoms yet increased hypotension risk. Catheter ablation showed lower success and more complications. CONCLUSIONS: Severe frailty and age ≥85 were associated with poorer outcomes, higher resourcutilization and reduced quality of life.