Antithrombotic Therapy in the Elderly

Capodanno, Davide; Angiolillo, Dominick J.

doi:10.1016/j.jacc.2010.04.063

Cited by 122 publications

(56 citation statements)

References 84 publications

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“…This population has also a higher risk of bleeding events versus a younger population 1,2 as a result of renal or hepatic dysfunction, age-related decrease in weight, drug interactions with more medications given to these patients, comorbidities, and frequent anemia. 4 All types of bleeding complications, that is, nuisance and minor and major bleedings increase significantly with age. 1,2,5 Whether the same interventional strategies can be applied to the elderly has been debated.…”

Section: Methodsmentioning

confidence: 99%

Platelet function monitoring in elderly patients on prasugrel after stenting for an acute coronary syndrome: Design of the randomized antarctic study

Cayla

Cuisset

Silvain

et al. 2014

American Heart Journal

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Section: Methodsmentioning

confidence: 99%

Platelet function monitoring in elderly patients on prasugrel after stenting for an acute coronary syndrome: Design of the randomized antarctic study

Cayla

Cuisset

Silvain

et al. 2014

American Heart Journal

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“…68 The European guidelines formally endorse the HAS-BLED (hypertension, abnormal renal/ liver function, stroke, bleeding history or predisposition, labile INR, elderly [>65], drugs/alcohol concomitantly) as a simple method to assess bleeding risk in patients with AF, with scores ≥3 indicating high risk. The HAS-BLED score has been found to predict bleeding significantly also in patients on triple antithrombotic therapy, with a relatively good discrimination (c statistic, 0.67).…”

Section: Risk Stratification and Balancementioning

confidence: 99%

Management of Antiplatelet and Anticoagulant Therapy in Patients With Atrial Fibrillation in the Setting of Acute Coronary Syndromes or Percutaneous Coronary Interventions

Capodanno

Angiolillo

2014

Circ: Cardiovascular Interventions

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A trial fibrillation (AF), the most common cardiac arrhythmia, occurs in 1% to 2% of the general population, with a prevalence varying from 0.5% in subjects 40 to 50 years old to 5% to 15% in the elderly who are >80 years old. [1][2][3] Stroke is the most feared complication of AF, resulting in death or disabling symptoms in a vast proportion of cases. 4 In the Framingham study, the age-adjusted incidence of stroke was 5-fold higher in subjects with AF, and the attributable risk raised from 1.5% at 50 to 59 years to 23.5% at 80 to 89 years. 5Chronic oral anticoagulation (OAC) therapy is the mainstay of stroke prevention in patients with AF at high risk for cardioembolic sequelae; ≈70% to 80% of all patients with AF have an indication for OAC, and coronary artery disease coexists in 20% to 30% of them. 6,7 With an estimated prevalence of AF in 1% to 2% of the population, it may be projected that ≈1 to 2 million patients on OAC in both the United States and Europe are candidates for coronary revascularization, often in the form of percutaneous coronary interventions (PCI). Patients undergoing PCI, as well as those who present with an acute coronary syndrome (ACS), also require dual antiplatelet therapy (DAPT), usually aspirin in combination with a platelet adenosine diphosphate P2Y 12 receptor antagonist, with the goal of reducing the risk of ischemic recurrences, including stent thrombosis. 8 However, the efficacy and safety of combining OAC with DAPT (triple antithrombotic therapy) in these patients is a topic of debate. In fact, although this combination can potentially prevent both thromboembolism and atherothrombotic events, it is also associated with an increased risk of severe bleeding. In a large nationwide registry of 40 812 patients hospitalized with myocardial infarction (MI), the risk of subsequent hospitalizations for bleeding increased with the number of antithrombotic drugs used, being 1.8-fold in patients on vitamin K antagonists (VKAs) and aspirin, 3.5-fold in patients on VKAs and clopidogrel, and 4-fold in patients on triple therapy, with numbers needed to harm of 45.4, 15.2, and 12.5, respectively. 9 On this background, treatment with OAC and antiplatelet agents requires careful consideration of the risks and benefits associated with each drug and their combination.On one hand, the challenge of balancing the risk of thromboembolism (ie, stroke) and atherothrombotic events (ie, stent thrombosis) and, on the other, the risk of bleeding demand for a timely review of the literature on using various combinations of OAC and antiplatelet therapies in patients with coexisting AF and coronary artery disease. This is also underscored by the recent availability of newer antithrombotic agents, including oral anticoagulants (ie, dabigatran, rivaroxaban, apixaban) and antiplatelets (ie, prasugrel, ticagrelor). This article reviews the evidence supporting antithrombotic agents for AF and ACS/PCI, and describes contemporary antithrombotic regimens and practical recommendations for patients with both condition...

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“…However, paucity of evidence-based data, safety concerns and economic disparities result in a substantial underuse of antithrombotic therapies in older patients [51]. Further, excess dosing of antithrombotic drugs occurs more frequently in vulnerable populations, including the elderly [52].…”

Section: Ancillary Antithrombotic Therapymentioning

confidence: 99%

Age Related Issues in Reperfusion of Myocardial Infarction

Carro

Bastiaenen

Kaski

2011

Cardiovasc Drugs Ther

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Advances in pharmacological treatment and effective early myocardial revascularization have led to improved clinical outcomes in patients with acute myocardial infarction (AMI). However, it has been suggested that compared to younger subjects, elderly AMI patients are less likely to receive evidence-based treatment. Several reasons have been postulated to explain this trend, including uncertainty regarding the benefits of the commonly used interventions in the older age group as well as increased risk associated with comorbidities. The diagnosis, management, and post-hospitalization care of elderly patients presenting with an acute coronary syndrome (ACS) pose many difficulties at present due, at least in part, to the fact that trial data are scanty as elderly patients have been poorly represented in most clinical trials. Thus it appears that these high-risk individuals are often managed with more conservative strategies, compared to younger patients. This article reviews current evidence regarding management of AMI in the elderly.

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Antithrombotic Therapy in the Elderly

Cited by 122 publications

References 84 publications

Platelet function monitoring in elderly patients on prasugrel after stenting for an acute coronary syndrome: Design of the randomized antarctic study

Platelet function monitoring in elderly patients on prasugrel after stenting for an acute coronary syndrome: Design of the randomized antarctic study

Management of Antiplatelet and Anticoagulant Therapy in Patients With Atrial Fibrillation in the Setting of Acute Coronary Syndromes or Percutaneous Coronary Interventions

Age Related Issues in Reperfusion of Myocardial Infarction

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