Effect of Age on Stroke Prevention Therapy in Patients With Atrial Fibrillation

Abstract

Background and Purpose-Stroke risk increases with age in patients who have nonvalvular atrial fibrillation. It is uncertain whether the efficacy of stroke prevention therapies in atrial fibrillation changes as patients age. The objective of this study was to determine the effect of age on the relative efficacy of oral anticoagulants (OAC) and antiplatelet (AP) therapy (including acetylsalicylic acid and triflusal) on ischemic stroke, serious bleeding, and vascular events in patients with atrial fibrillation. Methods-This is an analysis of the Atrial Fibrillation Investigators database, which contains patient level-data from randomized trials of stroke prevention in atrial fibrillation. We used Cox regression models with age as a continuous variable that controlled for sex, year of randomization, and history of cerebrovascular disease, diabetes, hypertension, and congestive heart failure. Outcomes included ischemic stroke, serious bleeding (intracranial hemorrhage or systemic bleeding requiring hospitalization, transfusion, or surgery), and cardiovascular events (ischemic stroke, myocardial infarction, systemic embolism, or vascular death). , whereas OAC increased risk of serious bleeding (1.56; 1.03 to 2.37). The relative benefit of OAC versus placebo or AP did not vary by patient age for any outcome. Compared with placebo, the relative benefit of AP for preventing ischemic stroke decreased significantly as patients aged (Pϭ0.01). Conclusions-As patients with atrial fibrillation age, the relative efficacy of AP to prevent ischemic stroke appears to decrease, whereas it does not change for OAC. Because stroke risk increases with age, the absolute benefit of OAC increases as patients get older. Results-The

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

“…Jeszcze większe korzyści obserwowano u pacjentów otrzymujących VKA, u których uzyskano duży TTR [432]. Leczenie przeciwpłytkowe zwiększa ryzyko krwawienia, zwłaszcza w przypadku stosowania podwójnego leczenia przeciwpłytkowego (2,0% vs. 1,3% podczas monoterapii lekiem przeciwpłytkowym; p < 0,001) [433], a częstość występowania krwawień jest podobna jak u pacjentów otrzymujących OAC [354,362,431,434]. Nie można w związku z tym zalecać leczenia przeciwpłytkowego w celu prewencji udaru mózgu u pacjentów z AF.…”

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

“…432 Antiplatelet therapy increases bleeding risk, especially dual antiplatelet therapy (2.0% vs. 1.3% with antiplatelet monotherapy; P , 0.001), 433 with bleeding rates that are similar to those on OAC. 354,362,431,434 Thus, antiplatelet therapy cannot be recommended for stroke prevention in AF patients. 449 -451 In these data sets, LAA occlusion was non-inferior to VKA treatment for the prevention of stroke in AF patients with moderate stroke risk, with a possibility of lower bleeding rates in the patients who continued follow-up.…”

Atrial Fibrillation and Vascular Disease—A Bad Combination

“…45 However, in this study, patients on warfarin were at increased risk of bleeding compared to aspirin. 45 In the article by van Walraven et al, 46 among AF patients the risk of vascular events increased with increasing age ( ≥ 65 years), and the absolute benefit of oral anticoagulation therapy compared to control/placeboalso increased with increasing age, whereas the absolute benefit of antiplatelet therapy declined. A similar pattern was seen for stroke, 46 but the magnitude of absolute benefit was less compared to that seen for vascular events.…”

“…45 In the article by van Walraven et al, 46 among AF patients the risk of vascular events increased with increasing age ( ≥ 65 years), and the absolute benefit of oral anticoagulation therapy compared to control/placeboalso increased with increasing age, whereas the absolute benefit of antiplatelet therapy declined. A similar pattern was seen for stroke, 46 but the magnitude of absolute benefit was less compared to that seen for vascular events. This reaffirms that in patients with AF, oral anticoagulation not only has a marked benefit regarding stroke, but also on all-cause mortality and vascular mortality.…”