Oral Anticoagulation Therapy for Elderly Patients With Atrial Fibrillation

Abstract

Elderly individuals are prone to nonvalvular atrial fibrillation (AF) with associated risks of arterial thromboembolic disease. Despite definitive guidelines, oral anticoagulant therapy (OAC) is notoriously underutilized in patients with AF. Physicians cite excessive bleeding risk as one reason they omit OAC for their older patients with AF. Improved understanding of the pathophysiology of age-related bleeding may improve risk-benefit assessments for warfarin and newer antithrombotic agents. We reviewed the literature to identify age-related pathophysiological elements that can exacerbate the likelihood of bleeding. In the context of the Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol concomitantly (HAS-BLED) bleeding risk framework, we highlight age-related physiological dynamics that predispose to hemorrhage. The combination of increased age (>65 years) with the other elements of the risk factor stratification model identifies patients with AF who are especially susceptible to OAC-related bleeding, irrespective of the agent used. Empirically adjusting OAC dose relative to these common bleeding risks may help to achieve an improved risk-benefit therapeutic ratio.

Assessment of factors affecting mortality in geriatric patients with warfarin overdose

“…[ 9 10 ] In the geriatric population, on the other hand, vascular biological changes appearing as connective tissue losses and small-vessel fragility in addition to pharmacokinetic/pharmacodynamic changes, and increased trauma exposure create a bleeding tendency as aging. [ 4 ] We observed a bleeding incidence of 14.2% in our geriatric population, which was similar to those reported for normal age groups. Traumatic bleedings, on the other hand, affected 5% of our patients.…”

“…Depending on pharmacodynamic alterations, the chance of having labile INR values and overdose episodes increase in parallel to age. [ 4 ] However, we determined that the predicted apparent effect of age factor, which led to a significant difference between the adult and geriatric population, was suppressed in our study population consisting of only geriatric patients. Furthermore, we found a greater rate of overdose in younger elderly (55.6%) than the older ones (44.4%).…”

“…As thromboembolic risk increases with aging, geriatric age group is the one that needs anticoagulation the most for therapeutic and prophylactic purposes. [ 1 4 ] Nevertheless, advanced age also brings about multimorbidity and polypharmacy. It has been reported that in geriatric population, the therapeutic range of warfarin could be attained in only half of time, and that the treatment is abandoned in less than a year in at least 25% of patients newly started on warfarin.…”