Non-vitamin K antagonist oral anticoagulants for stroke prevention in atrial fibrillation: safety issues in the elderly

Ajam, Tarek; Cumpian, Tabitha L; Tilkens, Blair L.; Jahangir, Imaan A; Frost, Jared; Ceretto, Cheryl; Jahangir, Arshad

doi:10.1080/17512433.2020.1842191

Cited by 6 publications

(6 citation statements)

References 107 publications

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“…Similarly, in patients with an indication, the risks of all strokes were not significantly different between the NOAC and the VKA groups (Seeger et al, 2017;Kawashima et al, 2020;Didier et al, 2021;Van Mieghem et al, 2021). However, NOACs have been shown to be more effective than VKA for reducing the risk of stroke in patients with nonvalvular atrial fibrillation (Granger et al, 2011;Ajam et al, 2020;Diener et al, 2020).…”

Section: Discussionmentioning

confidence: 95%

Non-Vitamin K Oral Anticoagulant After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Zhou

et al. 2022

Front. Pharmacol.

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Objective: We aimed to compare non-vitamin K oral anticoagulants (NOACs) with a traditional antithrombotic such as vitamin K antagonist (VKA) and antiplatelet agents in patients after transcatheter aortic valve replacement (TAVR).Methods: We conducted a search in PubMed, EMBASE, and the Cochrane Library until November 2021 for studies involving comparisons of any type of NOACs, including dabigatran, apixaban, rivaroxaban, and edoxaban, with VKA or antiplatelet agents after TAVR. A comparison of NOACs versus VKA was performed in patients with an indication for oral anticoagulation. In addition, we compared NOACs versus antiplatelet in patients without such indication. We calculated the hazard ratios with 95% confidence intervals (CIs) to determine long-term outcomes. The primary outcome was a combined endpoint consisting of all-cause mortality, stroke, major bleeding, or any related clinical adverse events. Secondary outcomes were all-cause mortality, major bleeding, and stroke, respectively.Results: A total of 10 studies including 10,563 patients after TAVR were included in this meta-analysis. There were no significant differences in any of the long-term outcomes between the NOAC and VKA groups. Although there were no significant differences in the combined endpoint, major bleeding, or stroke, a significant difference was observed in the all-cause mortality (HR 1.74, 95% CI 1.25–2.43, p = 0.001) between the NOAC and antiplatelet groups.Conclusion: For patients with an indication for oral anticoagulation after TAVR, NOACs seem to be associated with noninferior outcomes compared with VKA therapy. However, for patients without an indication for oral anticoagulation, NOACs appear to be associated with a higher risk of all-cause death as compared with antiplatelet treatment.Systematic Review Registration:https://clinicaltrials.gov/, identifier CRD42020155122.

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Section: Discussionmentioning

confidence: 95%

Non-Vitamin K Oral Anticoagulant After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Zhou

et al. 2022

Front. Pharmacol.

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“…Although there is sufficient evidence supporting the use of OACs in elderly patients with AF (14)(15)(16), poor adherence to guideline-directed anticoagulation has been reported (17). In addition, physicians are less likely to prescribe OACs in this population due to the risk of bleeding (18)(19)(20)(21). OAC treatment in real-world elderly patients with ACS and AF has rarely been reported.…”

Section: Introductionmentioning

confidence: 99%

Efficacy and Safety of Antithrombotic Therapy With Oral Anticoagulants in Real-World Elderly Patients With Acute Coronary Syndrome and Atrial Fibrillation

Li²,

Qin³

et al. 2022

Front. Cardiovasc. Med.

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BackgroundThe efficacy and safety of antithrombotic treatment with oral anticoagulants (OACs) in elderly patients with comorbidities of acute coronary syndrome (ACS) and atrial fibrillation (AF) are unclear.MethodsA cohort of hospitalized elderly patients (≥65 years of age) diagnosed with ACS and AF and treated with oral antithrombotic agents were consecutively recruited. Follow-up was performed for at least 1 year. Major adverse cardiac events (MACEs) were defined as a composite of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, and systemic embolism. The safety outcomes of bleeding were defined according to the Bleeding Academic Research Consortium (BARC) criteria.ResultsA cohort of 548 eligible patients (76 ± 6.6 years) was analyzed. Compared to the patients with OAC treatment (n = 184, 33.6%), patients treated without OAC (n = 364, 66.4%) were older, had a lower prevalence of persistent AF and unstable angina (UA), and more often presented with paroxysmal AF, acute myocardial infarction (AMI), stent implantation and dual antiplatelet therapy (DAPT). Compared to the patients without OAC treatment (n = 364, 66.4%), patients treated with OAC (n = 184, 33.6%) had a lower risk of MACEs at both the 1-year (4.3 vs. 15.1%, adjusted HR: 0.34, 95% CI: 0.15–0.80, p = 0.014) and 5-year (17.5 vs. 48.4%, adjusted HR: 0.36, 95% CI: 0.19–0.67, p = 0.001) follow-up. No significant difference was observed for bleeding events of BARC ≥2 between the groups (8.0 vs. 9.0%, adjusted HR: 1.17, 95% CI: 0.58–2.34, p = 0.667). Compared with warfarin-treated patients, the non-vitamin K antagonist oral anticoagulant-treated patients had lower risks of all-cause mortality (2.1 vs. 9.5%, HR: 0.18, 95% CI: 0.03–0.98, p = 0.047) and bleeding events of BARC ≥ 3 (2.1 vs. 4.8%, HR: 0.14, 95% CI: 0.02–1.10, p = 0.062).ConclusionsAntithrombotic therapy with OACs in elderly patients with ACS and AF was associated with a lower risk of ischemic events without an increase in bleeding events. In real-world practice, the clinical awareness of anticoagulation treatments in elderly patients with ACS and AF needs to be strengthened.

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“…66 Identifying genetic polymorphisms of substrates involved in the action of DOACs (thrombin and fibrin activity) and in the action of cytochrome CYP450 might contribute to the precision prescription. 120 Furthermore, the existence of a point -of -care test for the level of DOAC anticoagulation and better access to DOAC -specific reversal strategies could bolster clinical decision -making in emergent surgeries or in need for antidote in life -threatening bleeding conditions. Shorter half -life of DOACs has been also reported as a potential risk when doses are skipped due to noncompliance or forgetfulness.…”

Section: Follow -Up Risk Assessment Of the Oldest Oldmentioning

confidence: 99%

Oral anticoagulation challenges and therapeutic dilemmas in the very elderly: to treat and how to treat octogenarians and nonagenarians?

Papazoglou¹,

Moysidis²,

Κάρτας³

et al. 2023

Polish Archives of Internal Medicine

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Oral anticoagulation challenges and dilemmas in the very elderly 1 end, joint approaches from international working groups aimed to practically guide the anticoagulation decisions based on the existing observational data and despite the absence of an established threshold to define "elderly" and "very elderly." 4 Nevertheless, current evidence mostly concerns elderly populations (65-79 years of age), while very elderly populations (≥ 80 years of age) have been under -represented. 2 Given the rapid aging of the global population and great heterogeneity of the very elderly population, the current review aims at gathering and critically appraising the existing literature on the anticoagulation -related outcomes in octogenarians and nonagenarians with cardiovascular disease in need of OAC.Aging and organ function An ancient Greek saying warns "Fear old age, for it never comes alone."Introduction The positive correlation of age with major adverse cardiovascular events (MACEs), including bleeding and thromboembolism, has been long established. 1 The aging -induced organ dysfunction, along with the usually occurring multimorbidity and polypharmacy, create a critical conundrum over whether the anticoagulation benefits outweigh the bleeding risks. In real -world clinical practice, oral anticoagulation (OAC) drugs are usually suboptimally prescribed in elderly and very elderly patients in need of anticoagulation due to the fear of bleeding and the lack of specific randomized trials and guidelines. 2 The risk factors for ischemic and bleeding events often coexist, and bleeding episodes seem to account for higher mortality rates. 3 Hence, the development of individualized recommendations is particularly important in this setting. To that

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Non-vitamin K antagonist oral anticoagulants for stroke prevention in atrial fibrillation: safety issues in the elderly

Cited by 6 publications

References 107 publications

Non-Vitamin K Oral Anticoagulant After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Non-Vitamin K Oral Anticoagulant After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Efficacy and Safety of Antithrombotic Therapy With Oral Anticoagulants in Real-World Elderly Patients With Acute Coronary Syndrome and Atrial Fibrillation

Oral anticoagulation challenges and therapeutic dilemmas in the very elderly: to treat and how to treat octogenarians and nonagenarians?

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