Why are antithrombotic drugs not prescribed to octogenarian patients with atrial fibrillation at risk of stroke?

Non-adherence to Thromboprophylaxis Guidelines in Atrial Fibrillation: A Narrative Review of the Extent of and Factors in Guideline Non-adherence

“…To clearly identify guideline non-adherence, undertreatment in particular, several studies included only patients at high risk for stroke. [32][33][34][35][36][37][38][39][40][41][42] The patients included in these studies either had CHA2DS2-VASc or CHADS2 scores ≥2 [33][34][35][36][37][38][39][40] or were aged ≥75 years old [32,41,42], all of which made them at high risk. Undertreatment in these high-risk patients ranged from as low as 19.7% [38] to as high as 95.2% [40], with the majority of the studies reporting undertreatment between 40% and 50%.…”

“…[32][33][34][35][36][37][38][39][40][41][42] The patients included in these studies either had CHA2DS2-VASc or CHADS2 scores ≥2 [33][34][35][36][37][38][39][40] or were aged ≥75 years old [32,41,42], all of which made them at high risk. Undertreatment in these high-risk patients ranged from as low as 19.7% [38] to as high as 95.2% [40], with the majority of the studies reporting undertreatment between 40% and 50%. [32, 33, 35-37, 39, 42] Of note, the study by Piccini et al, with 19.7% undertreatment, was part of a quality improvement initiative in hospitalized patients targeting guideline adherence and the extent of undertreatment before hospital admission, and before the intervention, in this study was 40.5%.…”

“…[38] In the study by Formiga et al, the relatively higher proportion of octogenarians (40%) may have been the primary contributor to higher undertreatment (95.2%in their study). [40] When it comes to overtreatment, between 0.6% and 79.8% of patients at low risk of stroke who did not need any antithrombotic medication received treatment, which would be considered to be overtreatment. [18,22,26,31,33,35,[43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62] Recent studies that investigated trends in guideline adherence have shown substantial improvements in guideline adherence over time.…”

“…[39] The presence of comorbidities such as ischemic heart disease, cancer, chronic kidney disease, chronic obstructive pulmonary disease, dementia, peripheral arterial disease, and heart failure have all been associated with guideline non-adherence, in particular less OAC prescribing. [20,32,40,58,69,73,74] On the other hand, patients with deep venous thrombosis, hypertension, valvular heart disease, and higher body mass index are more likely to receive OACs. [20,61,73,83] Prescription of antiplatelet agents or non-steroidal anti-inflammatory drugs [36,41,56,64], recurrent falls or history of falls [32,77], first detected and/or paroxysmal AF [32,35], alcohol abuse [47,73], pharmacological (vs electrical) cardioversion [35], rural residence and illiteracy [20], difficult access to monitoring [40] and frailty [84] have all been associated with underprescription of OACs.…”

“…[20,32,40,58,69,73,74] On the other hand, patients with deep venous thrombosis, hypertension, valvular heart disease, and higher body mass index are more likely to receive OACs. [20,61,73,83] Prescription of antiplatelet agents or non-steroidal anti-inflammatory drugs [36,41,56,64], recurrent falls or history of falls [32,77], first detected and/or paroxysmal AF [32,35], alcohol abuse [47,73], pharmacological (vs electrical) cardioversion [35], rural residence and illiteracy [20], difficult access to monitoring [40] and frailty [84] have all been associated with underprescription of OACs. Most of the above factors that contribute to guideline non-adherence share the common feature of increasing the risk of bleeding and could be the underlying reason for their contribution in guideline non-adherence.…”