Anticoagulation for stroke prevention in elderly patients with non-valvular atrial fibrillation: what are the obstacles?

Cw, Wong

doi:10.12809/hkmj154803

Cited by 7 publications

(8 citation statements)

References 35 publications

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“…Among the reasons found in other series for the non-use of anticoagulant treatment were the risk of falls, history of hemorrhage, age, rejection of the family or patient, the presence of dementia and functional disability. 10,27 One in nine (11.6%) of the present patients treated with anticoagulants received a DOAC. These were mainly non-institutionalized patients in secondary prevention.…”

Section: Discussionmentioning

confidence: 85%

“…A younger age, the presence of heart failure or venous thromboembolism, higher functional capacity, higher BMI (as an indirect marker of lower sarcopenia), lower comorbidity (Charlson Comorbidity Index score) and a higher number of drugs were independently associated with anticoagulant treatment in the present population. Among the reasons found in other series for the non‐use of anticoagulant treatment were the risk of falls, history of hemorrhage, age, rejection of the family or patient, the presence of dementia and functional disability …”

Section: Discussionmentioning

confidence: 96%

“…Less than half of the nonagenarians with AF receive anticoagulant therapy . This low anticoagulation use can be influenced, in addition to the increased risk of hemorrhage, by associated geriatric syndromes, important comorbidity, greater fragility, polypharmacy and the presence of cognitive impairment . There is limited information on the factors that influence the maintenance of anticoagulant treatment at these ages.…”

Section: Introductionmentioning

confidence: 99%

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Prevalence of atrial fibrillation and associated anticoagulant therapy in the nonagenarian population of the Community of Madrid, Spain

Lahoz¹,

Cárdenas

Salinero-Fort

et al. 2018

Geriatrics Gerontology Int

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Aims The objective of the present study was to evaluate the prevalence of atrial fibrillation (AF) in nonagenarians living in the Community of Madrid, their clinical features, the use of anticoagulant therapy and factors associated with its use. Methods This was a cross‐sectional study of 59 423 individuals aged ≥90 years, living in the Community of Madrid on 31 December 2015. Clinical information was obtained from a database that includes information from electronic medical records collected by 3881 general practitioners in primary care. Results Some 16.95% of nonagenarians (n = 10 077) were diagnosed with atrial fibrillation. These individuals have a higher prevalence of classic risk factors and established cardiovascular disease, as well as higher comorbidity. Of these, 67.6% received anticoagulant therapy, 27.9% received antiplatelet agents and 7.2% received both treatments simultaneously. Of the participants administered anticoagulation, 11.6% received a direct oral anticoagulant. The use of anticoagulant therapy was associated with a younger age, the presence of heart failure or venous thromboembolism, the absence of hypertension, a higher Barthel Index score, a greater number of prescribed drugs, a higher body mass index and a lower Charlson Comorbidity Index score. Conclusions Nonagenarians with atrial fibrillation have a high risk of stroke; however, high comorbidity and functional impairment have limited the use of anticoagulant therapy. Geriatr Gerontol Int 2019; 19: 203–207.

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Section: Discussionmentioning

confidence: 85%

Section: Discussionmentioning

confidence: 96%

Section: Introductionmentioning

confidence: 99%

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Prevalence of atrial fibrillation and associated anticoagulant therapy in the nonagenarian population of the Community of Madrid, Spain

Lahoz¹,

Cárdenas

Salinero-Fort

et al. 2018

Geriatrics Gerontology Int

View full text Add to dashboard Cite

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“…The lower risk of intracranial bleeding, as well as the practical advantages of NOACs over vitamin K antagonists (VKA), including a fixed dose, no need for International Normalized Ratio (INR) monitoring and fewer food and drug interactions, likely explain the observed increase in the proportion of patients receiving anticoagulant therapy. [1][2][3] Although this reduces the concern for "undertreatment" (ie, receiving no anticoagulant therapy at all), 4 new concerns have emerged about "underdosing" or off-label dose reduction: patients receiving an NOAC dose lower than recommended in the guidelines. 5,6 Previous studies reporting on the prevalence of off-label NOAC dose reduction have shown variable results, with estimates between 8% and 39%.…”

Section: Introductionmentioning

confidence: 99%

“…Non‐vitamin K oral anticoagulants (NOACs, or direct acting oral anticoagulants, DOACs) play a central role in anticoagulant treatment for stroke prevention in patients with non‐valvular atrial fibrillation (AF). The lower risk of intracranial bleeding, as well as the practical advantages of NOACs over vitamin K antagonists (VKA), including a fixed dose, no need for International Normalized Ratio (INR) monitoring and fewer food and drug interactions, likely explain the observed increase in the proportion of patients receiving anticoagulant therapy 1–3 . Although this reduces the concern for “undertreatment” (ie, receiving no anticoagulant therapy at all), 4 new concerns have emerged about “underdosing” or off‐label dose reduction: patients receiving an NOAC dose lower than recommended in the guidelines 5,6 …”

Section: Introductionmentioning

confidence: 99%

Safety of off‐label dose reduction of non‐vitamin K antagonist oral anticoagulants in patients with atrial fibrillation

Dries

Pajouheshnia

Ham

et al. 2022

Brit J Clinical Pharma

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Aim To investigate the effects of off‐label non‐vitamin K oral anticoagulant (NOAC) dose reduction compared with on‐label standard dosing in atrial fibrillation (AF) patients in routine care. Methods Population‐based cohort study using data from the United Kingdom Clinical Practice Research Datalink, comparing adults with non‐valvular AF receiving an off‐label reduced NOAC dose to patients receiving an on‐label standard dose. Outcomes were ischaemic stroke, major/non‐major bleeding and mortality. Inverse probability of treatment weighting and inverse probability of censoring weighting on the propensity score were applied to adjust for confounding and informative censoring. Results Off‐label dose reduction occurred in 2466 patients (8.0%), compared with 18 108 (58.5%) on‐label standard‐dose users. Median age was 80 years (interquartile range [IQR] 73.0‐86.0) versus 72 years (IQR 66‐78), respectively. Incidence rates were higher in the off‐label dose reduction group compared to the on‐label standard dose group, for ischaemic stroke (0.94 vs 0.70 per 100 person years), major bleeding (1.48 vs 0.83), non‐major bleeding (6.78 vs 6.16) and mortality (10.12 vs 3.72). Adjusted analyses resulted in a hazard ratio of 0.95 (95% confidence interval [CI] 0.57‐1.60) for ischaemic stroke, 0.88 (95% CI 0.57‐1.35) for major bleeding, 0.81 (95% CI 0.67‐0.98) for non‐major bleeding and 1.34 (95% CI 1.12‐1.61) for mortality. Conclusion In this large population‐based study, the hazards for ischaemic stroke and major bleeding were low, and similar in AF patients receiving an off‐label reduced NOAC dose compared with on‐label standard dose users, while non‐major bleeding risk appeared to be lower and mortality risk higher. Caution towards prescribing an off‐label reduced NOAC dose is therefore required.

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Chinese expert consensus on antithrombotic management of high‐risk elderly patients with chronic coronary syndrome

Zhang

Wang

2023

Aging Medicine

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The prevalence and mortality of coronary artery disease (CAD) in China are still at an increasing stage. CAD can be classified as acute coronary syndrome (ACS) or chronic coronary syndrome (CCS). CCS is the main manifestation type of elderly patients with CAD, with a large number of patients, long course of disease, and poor prognosis, leading to decreased quality of life and heavy disease burden and economic burden. Especially in patients with high‐risk CCS, the case fatality rate and total mortality are high. In order to better standardize the antithrombotic treatment of elderly patients with high‐risk CCS, the Geriatrics Branch of the Chinese Medical Association organizes domestic experts to develop this consensus for clinicians' reference based on published clinical research evidence, combined with relevant guidelines, consensus, and expert recommendations in China and abroad.

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Anticoagulation for stroke prevention in elderly patients with non-valvular atrial fibrillation: what are the obstacles?

Cited by 7 publications

References 35 publications

Prevalence of atrial fibrillation and associated anticoagulant therapy in the nonagenarian population of the Community of Madrid, Spain

Prevalence of atrial fibrillation and associated anticoagulant therapy in the nonagenarian population of the Community of Madrid, Spain

Safety of off‐label dose reduction of non‐vitamin K antagonist oral anticoagulants in patients with atrial fibrillation

Chinese expert consensus on antithrombotic management of high‐risk elderly patients with chronic coronary syndrome

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