Frailty adds important complexity to the management of atrial fibrillation (AF) in older adults. A systematic review published in the Indian Heart Journal found that frailty and advanced age were consistently associated with worse outcomes, including higher mortality, stroke, bleeding, and reduced quality of life.

The review examined studies published between 2015 and 2025, including cohort studies, clinical trials, and meta-analyses. Reported outcomes included mortality, stroke, major bleeding, functional decline, recurrence, healthcare costs, and quality of life. Frailty was assessed using validated tools such as the Clinical Frailty Scale.

Across included studies, frail patients with AF had a two- to threefold higher mortality risk than non-frail peers. Frailty was also associated with a 40% to 50% greater incidence of stroke and major bleeding.

Among treatment strategies, low-dose non-vitamin K antagonist oral anticoagulants (NOACs) reduced stroke risk in frail octogenarians, although bleeding risk remained elevated. Rate-control therapy improved symptoms but was associated with greater hypotension risk. Catheter ablation showed lower success rates and more complications in frail populations.

Severe frailty and age 85 years or older were associated with poorer outcomes, higher resource utilization, and lower quality of life. The findings highlight the need to incorporate frailty assessment into AF treatment decisions in older adults.