Age as a Risk Factor for Stroke in Atrial Fibrillation Patients

Abstract

The prevalence of atrial fibrillation (AF) is related to age and is projected to rise exponentially as the population ages and the prevalence of cardiovascular risk factors increases. The risk of ischemic stroke is significantly increased in AF patients, and there is evidence of a graded increased risk of stroke associated with advancing age. Oral anticoagulation (OAC) is far more effective than antiplatelet agents at reducing stroke risk in patients with AF. Therefore, increasing numbers of elderly patients are candidates for, and could benefit from, the use of anticoagulants. However, elderly people with AF are less likely to receive OAC therapy. This is mainly due to concerns about a higher risk of OAC-associated hemorrhage in the elderly population. Until recently, older patients were under-represented in randomized controlled trials of OAC versus placebo or antiplatelet therapy, and therefore the evidence base for the value of OAC in the elderly population was not known. However, analyses of the available trial data indicate that the expected net clinical benefit of warfarin therapy is highest among patients with the highest untreated risk for stroke, which includes the oldest age category. An important caveat with warfarin treatment is maintenance of a therapeutic international normalized ratio, regardless of the age of the patient, where time in therapeutic range should be > or =65%. Therefore, age alone should not prevent prescription of OAC in elderly patients, given an appropriate stroke and bleeding risk stratification.

Current Status and Time Trends of Oral Anticoagulation Use Among Chinese Patients With Nonvalvular Atrial Fibrillation

“…25 One possible explanation may be the concerns about a higher risk of OAC-associated hemorrhage in the elderly population. 26 However, observational studies and meta-analyses 27,28 show comparable rates of major bleeding with warfarin and aspirin, whereas stroke risk is significantly reduced with warfarin in patients with AF aged >75 years. The observation that persistent AF patients were more likely to have OAC has been seen in other studies.…”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…leczenia AF jako metoda terapii pacjentów z objawowym, opornym na leczenie przetrwałym AF lub AF po ablacji w celu zmniejszenia objawów IIa C [808,832] Operacja labiryntowania, najlepiej obejmująca oba przedsionki, powinna być rozważana w celu zmniejszenia objawów przypisywanych AF u pacjentów poddawanych operacji kardiochirurgicznej, z uwzględnieniem dodatkowego ryzyka zabiegowego i korzyści z leczenia w celu kontroli rytmu serca [362] prób klinicznych z użyciem NOAC [39] oraz analiz przeprowadzonych u starszych Amerykanów (Medicare) [396]. Pacjenci w podeszłym wieku z AF są bardziej zagrożeni udarem mózgu, a wiec prawdopodobieństwo korzyści z OAC jest u nich większe niż u młodszych pacjentów [841], a mimo to OAC jest wciąż niedostatecznie wykorzystywane u osób w podeszłym wieku [220,842]. Mimo że w odniesieniu do innych metod leczenia stosowanych w AF uzyskano mniej dowodów, to dostępne dane przemawiają za stosowaniem dostępnych interwencji wykorzystywanych do kontroli częstości rytmu komór i rytmu serca, włącznie ze stymulatorami i ablacją przezcewnikową, bez uzasadnienia różnicowania leczenia zależnie od wieku.…”

Risk of Stroke or Systemic Embolism in Atrial Fibrillation Patients Treated With Warfarin

“…Because stroke risk increases with age, there is a potential greater net clinical benefit of OAC among elderly patients. 21,22 Several studies investigating the risk of stroke in AF patients have found women to be at higher risk than men. [23][24][25][26][27] Two recently published large registry-based studies 25,26 on nonanticoagulated patients found a significantly higher risk of stroke overall for women of 18% and 14%, respectively.…”