Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach

Abstract

Background: Atrial fibrillation (AF) in the elderly is a complex condition. It has a direct impact on the underuse of antithrombotic therapy reported in this population. Discussion: All patients aged ≥75 years with AF have an individual yearly risk of stroke >4 %. However, the risk of hemorrhage is also increased. Moreover, in this population it is common the presence of other comorbidities, cognitive disorders, risk of falls and polymedication. This may lead to an underuse of anticoagulant therapy. Direct oral anticoagulants (DOACs) are at least as effective as conventional therapy, but with lesser risk of intracranial hemorrhage. The simplification of treatment with these drugs may be an advantage in patients with cognitive impairment. The great majority of elderly patients with AF should receive anticoagulant therapy, unless an unequivocal contraindication. DOACs may be the drugs of choice in many elderly patients with AF.

Real‐World Clinical Characteristics and Treatment Patterns of Individuals Aged 80 and Older with Nonvalvular Atrial Fibrillation: Results from the ReAl‐life Multicenter Survey Evaluating Stroke Study

“…Antiarrhythmic drug therapies were also recorded. For individuals undergoing VKA therapy, time in therapeutic range (TTR) was calculated using the traditional method: ratio of in‐range INR measurments to all INR meaurements of an individual. Congestive heart failure or left ventricular dysfunction, Hypertension, Aged 75 and older, Diabetes mellitus, thromboembolism or Stroke history, Vascular disease, aged 65 to 74, and Sex (CHA 2 DS 2 VASc) score was calculated to assess risk of thromboembolic events, and bleeding risk was evaluated according to Hypertension, renal or liver failure, Stroke history, Bleeding history, Labile INR, Aged 65 and older, Drugs or alcohol (HAS‐BLED) score.…”

Direct oral anticoagulant use and the incidence of bleeding in the very elderly with atrial fibrillation

“…The use of anticoagulation to reduce this risk, therefore, requires strong consideration in all eligible individuals. Unfortunately, increased age is not only a risk factor for AF and stroke, but also poses a higher bleeding risk with anticoagulation[3]. …”

Decision Algorithms for Direct Oral Anticoagulant Use in Patients With Nonvalvular Atrial Fibrillation: A Practical Guide for Neurologists

“…It is important to define and monitor all known risk factors which may increase the risk of hemorrhages in the elderly patients, such as high blood pressure, concomitant use of nonsteroidal anti-inflammatory drugs, and alcohol abuse. 24 Furthermore, thrombocytopenia and anemia are frequently encountered in elderly patients, and anticoagulation is generally contraindicated when platelet count is lower than 50 000/dL, and when it ranges between 50 000 and 100 000/dL. Anemia predicts thromboembolic events, bleeding complications, and mortality in patients with AF but is not per se a contraindication for starting anticoagulation; strict control and follow-up are advisable.…”

“…Anemia predicts thromboembolic events, bleeding complications, and mortality in patients with AF but is not per se a contraindication for starting anticoagulation; strict control and follow-up are advisable. 24 Renal impairment is also common in the elderly patients, especially in those with permanent AF, as it may worsen both thromboembolic and hemorrhagic risk outcomes. However, kidney dysfunction does not generally contraindicate anticoagulation.…”