Thromboembolic Prevention in Frail Elderly Patients With Atrial Fibrillation: A Practical Algorithm

Oral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence

“…Indeed, it has been shown that many hospitalized elderly patients at high stroke risk might not be optimal candidates for warfarin [38]. In the absence of robust evidence driving the best use of anticoagulation in frail and complex older patients, a multidimensional algorithm covering both a standard ischemic and bleeding risk assessment and an additional anticoagulation-focused frailty assessment has been recently suggested to achieve a tailored approach in older AF patients [39].…”

“…It is likely that OAT may sometimes be perceived by physicians as "futile" or potentially harmful in patients with short life-expectancy. Unfortunately, although some theoretical tools have been recently suggested to address frailty in this context [39], by now there are not validated and widely acknowledged methods to identify those older patients who, in reason of their poor general health and/or functional status, are expected not to derive a net clinical benefit from anticoagulation, and should therefore not be prescribed OAT.…”

“…Selection of the "right" anticoagulant drug for stroke prevention in the elderly should be based on a global evaluation of patient's characteristics, including age, comorbidity, kidney function, overall and gastrointestinal bleeding risks, ischemic or hemorrhagic stroke history, patient's preference for low pill burden and, obviously, costs [39,61,107] (Fig. 1).…”

Frailty and Cardiovascular Disease

“…In fact, frailty is the third most cited reason for not prescribing an oral anticoagulant. This makes the report by Granzera et al more pertinent as the population ages [61]. In this study, he provides an approach to deciding if oral anticoagulation is appropriate in elderly frail patients (Figure 2).…”

“…also discussed what factors should go into making the decision of whether to use warfarin or novel oral anticoagulants (NOACs) in frail patients [61]. Severe renal impairment, severe liver impairment, and poor adherence favored the use of warfarin.…”