Tratamiento antitrombótico en el paciente anciano con fibrilación auricular

The problem of underdosing with direct-acting oral anticoagulants in elderly patients with nonvalvular atrial fibrillation

“…DOACs, which are free of many of the limitations of VKAs and have a better safety and efficacy profile, have facilitated prescription of anticoagulation therapy [2]. Although empirical data on dose adjustment have many weaknesses, and a causal inference between underdosing and stroke or bleeding risk from real-life studies cannot directly been established, the majority of studies suggest that prescription of DOACs is currently hampered by underdosing, which entails a greater risk of stroke [4,[67][68][69][70][76][77][78][79][80][81][82][83][84][85].…”

“…This is clearly an erroneous approach with potentially catastrophic consequences for the patient. In addition, the fact that there are differences in the criteria for dose adjustment between DOACs means that physicians are sometimes not sure how to adjust the dose for a specific drug [2,4,[67][68][69][70]. In addition, while prescription of VKAs is hampered by poor anticoagulation resulting from our inability to achieve a suitable time within the therapeutic range in around half of patients [90,91], with DOACs, we are placing patients at a reducible risk of stroke, with the only supporting argument being that an inadequate dose is indicated [83].…”

“…AF-associated stroke has a high mortality rate, which can reach 50% at 1 year of follow-up in some series [17]; in survivors, the frequency of disability is high, as is the risk of recurrence. These figures are worse in the elderly [2,18,19], thus making appropriate prevention of thromboembolic complications essential in this population [20]. Therefore, the risk of stroke and bleeding must be assessed on an individual basis [21].…”

“…For decades, VKAs were considered the standard oral anticoagulant therapy in patients with AF, even in the elderly population [44,45,48]. However, VKAs have a number of disadvantages (e.g., variable response, need for periodic control of anticoagulation and multiple interactions), which, together with concern over bleeding and difficult management, have limited their use in daily clinical practice [2,48]. [27,[49][50][51][52][53][54][55][56][57].…”

Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach

“…AF is a complex condition in elderly subjects due to their high number of comorbidities, including cardiovascular and kidney diseases, cognitive disorders, falls and polypharmacy [ 7 ]. As a result, the management of these patients is challenging in most cases.…”