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

Abstract

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

A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients—A Review PART II—Pharmacological Approach for Management of Elderly Patients with Peripheral Atherosclerotic Lesions outside Coronary Territory

“…Atrial fibrillation patients over 65 years of age with coexisting non-coronary artery atherosclerosis receive a CHA2DS2-VASc score of 2. However, there is an ongoing dilemma in very elderly patients of how to treat octogenarians and nonagenarians [ 109 ]. An exception is 4 weeks after endovascular revascularization with stent implantation in a non-coronary artery, in which an anticoagulant and an antiplatelet drug (preferably clopidogrel) are used to reduce the risk of stent thrombosis [ 83 ].…”

Upper endoscopy in elderly patients: a multicentre study.

“…Data of two large, endoscopic series performed in Italy two decades ago showed that the overall prevalence of peptic ulcers and cancers was 10.6% in elderly and 3.1% in younger (< 65 years) patients [9,10]. However, prevalence of these lesions, as well as of other relevant endoscopic ndings, may change in elderly due to various factors, such as different use of anti-thrombotic therapies and decreasing prevalence of H. pylori infection in the last decades [11,12]. Moreover, therapy with proton pump inhibitors (PPIs) for gastroprotection towards ulcers, erosions and bleeding in patients receiving NSAIDs or anticoagulant was variably performed in clinical practice, including elderly [13,14].…”