New EHRA expert consensus on the management of arrhythmia in frailty syndrome

By Dr. Timothy Swinn
Edited by Dr. Ahmed El-Medany 

The European Heart Rhythm Association has recently released the first consensus statement on management of arrhythmias in frailty syndrome.1 The group recognise that the number of adults over the age of 60 and 80 years are forecast to double and quadruple respectively by 2050, meaning that frailty syndrome will only become more prevalent. Despite this, frail patients are often excluded from trials and addressing this paucity of evidence and guidance is vital.

The group discuss varying definitions of frailty and pre-frailty and highlight inconsistency of frailty assessment as a knowledge gap. Nonetheless, physicians should be aware of common features of frailty syndrome (malnutrition/anorexia, sarcopenia, heart failure, and falls) and should address these early through non-pharmacological and pharmacological treatments. Furthermore, physicians should be mindful of altered pharmacokinetics due to a variety of mechanisms (see table 4 in the consensus statement for a detailed list).

The statement then addresses specific areas within arrhythmia management:


The statement recommends using standard pacing indications in a frail cohort and highlights that untreated sinus node dysfunction confers a poorer prognosis in frail patients with a higher rate of syncope, AF, and heart failure. The group recommends considering single-lead (VVI) permanent pacemaker (PPM) implantation as dual lead (DDD) has not been shown to be advantageous in this group.2 They highlight that frailty itself is not a contraindication to PPM implantation, although some complications (lead erosion due to low BMI, pneumothorax, and lead dislodgement) may be more common.

Implantable cardioverter defibrillators/Cardiac resynchornisation therapy devices

Implantable cardioverter defibrillators (ICDs) may be beneficial when life expectancy is greater than one year although may not prolong life expectancy due to competing causes for death in this group. The consensus statement recommends taking frailty into account when programming ICDs, namely reducing number of shocks, and reinforces the importance of open discussion with patients and carers about how ICD may influence mode of death (i.e. making sudden cardiac death less likely may increase the chance of a slower process causing death, which some patients may find less desirable).

Frailty also appears associated with a higher chance of non-response to cardiac resynchronisation therapy (CRT). It is therefore important to optimise non-pharmacologic interventions (namely nutrition and mobility) prior to CRT implantation.

As with all devices, open discussions are required around whether to program a device off and whether lead replacement or device upgrade is appropriate.

Atrial fibrillation

The consensus statement recommends anticoagulation in the context of all non-gender CHA2DS2-VASc stroke risk factors. Frailty, cognitive decline, and falls are generally not reasons to withhold anticoagulation. However frail patients require regular review of stroke vs bleeding risk. 


The consensus statement is a thorough review of general and specific aspects of frailty relating to arrhythmias and their management in a patient group that is often under-represented in clinical trials. In time, identified gaps in knowledge will be addressed and new evidence featured in future iterations of this consensus. 

The full statement can be found here: 


  1. Savelieva I, Fumagalli S, Kenny RA, Anker S, Benetos A, Boriani G, et al. EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). EP Eur. 2023 Apr 28;25(4):1249–76.
  2. Toff WD, Camm AJ, Skehan JD, United Kingdom Pacing and Cardiovascular Events Trial Investigators. Single-chamber versus dual-chamber pacing for high-grade atrioventricular block. N Engl J Med. 2005 Jul 14;353(2):145–55.