Vitamin K Antagonists and Direct Oral Anticoagulants in Nonagenarian Patients With Atrial Fibrillation

Effectiveness and Safety of Oral Anticoagulants in Older Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

“…In terms of safety, NOACs were associated with a similar ( Giustozzi et al., 2019 ; Mitchell et al., 2019 ; Nishida et al., 2019 ; Poli et al., 2019 ; Russo et al., 2019 ; Chao et al., 2020 ) to lower ( Kim et al., 2019 ; Shinohara et al., 2019 ; Nishida et al., 2019 ; Chao et al., 2020 ; Wong et al., 2020 ) major bleeding, a similar ( Hohmann et al., 2019 ; Kim et al., 2019 ) to significantly higher ( Mitchell et al., 2019 ; Wong et al., 2020 ) gastrointestinal bleeding and a lower ( Hohmann et al., 2019 ; Kim et al., 2019 ; Mitchell et al., 2019 ; Chao et al., 2020 ; Wong et al., 2020 ) intracranial bleeding risk (except for a similar risk in one study) ( Russo et al., 2019 ) as compared to VKAs in AF patients ≥75, ≥80, ≥85 and ≥90 years old ( Shinohara et al., 2019 ; Hohmann et al., 2019 ; Nishida et al., 2019 ; Mitchell et al., 2019 ; Giustozzi et al., 2019 ; Russo et al., 2019 ; Kim et al., 2019 ; Poli et al., 2019 ; Chao et al., 2020 ). Interestingly, in AF patients ≥90 years old, the use of NOACs as compared to no anticoagulation was associated with a significantly lower risk for the composite effectiveness endpoint (stroke/SE, pulmonary embolism and death), and a borderline similar risk for major bleeding and intracranial bleeding ( Raposeiras-Roubín et al., 2020 ). On the contrary, VKAs as compared to no anticoagulation were associated with a similar risk for the composite effectiveness endpoint, but a significantly higher risk for major bleeding and intracranial bleeding ( Raposeiras-Roubín et al., 2020 ).…”

“…Interestingly, in AF patients ≥90 years old, the use of NOACs as compared to no anticoagulation was associated with a significantly lower risk for the composite effectiveness endpoint (stroke/SE, pulmonary embolism and death), and a borderline similar risk for major bleeding and intracranial bleeding ( Raposeiras-Roubín et al., 2020 ). On the contrary, VKAs as compared to no anticoagulation were associated with a similar risk for the composite effectiveness endpoint, but a significantly higher risk for major bleeding and intracranial bleeding ( Raposeiras-Roubín et al., 2020 ). This differential safety profile was also illustrated in a Markov state transition model, demonstrating a lack of net clinical benefit for warfarin as compared to no anticoagulation after the age of 87, whereas only after the age of 92 for apixaban ( Shah et al., 2019 ).…”

“…In conclusion, observational studies have illustrated the non-inferior to superior effectiveness and safety profile of NOACs as compared to VKAs in older AF patients, with most reassuring data on apixaban. Importantly, even in the oldest AF patients ≥90 years old, NOAC use was still beneficial over OAC discontinuation ( Raposeiras-Roubín et al., 2020 ).…”

“…Consequently, OACs tend to be inappropriately underdosed or discontinued in these patients subgroups ( Viscogliosi et al., 2017 ; Oqab et al., 2018 ; Madhavan et al., 2019 ; Proietti et al., 2019 ; Besford et al., 2020 ; Kapoor et al., 2020 ; Sanghai et al., 2020 ). However, even in AF patients ≥90 years old ( Raposeiras-Roubín et al., 2020 ), at high risk of falling ( Man-Son-Hing et al., 1999 ) or with dementia ( Orkaby et al., 2017 ; Subic et al., 2018 ), OAC continuation was still beneficial compared to omitting the OAC. Therefore, very high age, recent fall or cognitive impairment should not be considered as strict contraindications for OAC use, provided that an individual benefit-risk assessment is performed.…”

“…Studies including even older AF patients (e.g. ≥80, 85, or 90 years old) were not included in the meta-analysis, due to concerns of channelling bias ( Alcusky et al., 2020 ) in the introduction years and selective prescribing (of NOACs to more comorbid patients) later on, and more frequent inappropriate NOAC dosing in observational studies ( Shinohara et al., 2019 ; Raposeiras-Roubín et al., 2020 ) in the oldest AF patients. However, these results were included in an additional subgroup analysis.…”