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

Practical use of Direct Oral Anti Coagulants (DOACs) in the older persons with atrial fibrillation.

“…Several studies and meta-analysis based on results of DOAC phase III RCTs have provided extensive information about efficacy, safety and clinical benefit of DOACs compared with warfarin in elderly persons [3][4][5], and recent European recommendations dealt with some wedge issues concerning use of DOACs in older persons [2]. For a more in depth evaluation of persistent uncertainties about DOACs practical use in real world elderly people, scientific literature focused on use of DOACs in older persons published in the last 8 years was retrieved by the authors (MB, NM) from the MEDLINE database using the terms "atrial fibrillation" AND "antithrombotic therapy", OR "new oral anticoagulants" OR "direct oral anticoagulants", OR "aged" OR "elderly" OR "older" as keywords.…”

“…Indeed, only 40-60% of RW AF patients enrolled in the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) registry taking warfarin would have met the selection criteria adopted for phase III DOACs trials [15]. Whereas patients with severe comorbidities, reduced life expectancy, potentially interacting drugs, and mild-to-moderate blood work abnormalities were systematically excluded from phase III DOACs trials [4], RW AF patients are older, more frequently of female gender, with high prevalence of comorbidities and of functional and/or cognitive impairment [9,12,13,16,17].…”

“…Despite recent studies reinforced the evidence of net clinical benefit of OAT, including DOACs, in extremely elderly community-dwelling persons (aged > =85 years) [82], prescription of OAT to older AF patients is often a troublesome decision, involving a global evaluation of health, residual life-expectancy, functional and cognitive status, rather than a simple addition of variables within cardio-embolic and bleeding risk scales [4]. It is likely that sometimes physicians perceive OAT as "futile" or potentially harmful in patients with multi-morbidity and short life-expectancy, and, moreover, cost-effectiveness considerations might affect decision about DOACs prescription in these patients.…”

“…Barco et al reported a significant reduction in stroke and thromboembolic events and in intracranial hemorrhages, compared to warfarin, in patients receiving full-dose dabigatran and apixaban, this latter being also associated with a reduced incidence of major bleedings [3]. In a review of DOACs phase III trials, including also the data from the ENGAGE AF TIMI 48 study, in patients aged ≥ 75 years [4], apixaban and higher-dose dabigatran were associated with a significant reduction of stroke/systemic embolism, whereas major bleeding were significantly reduced in patients receiving apixaban and edoxaban compared with warfarin; all DOACs, with the exception of rivaroxaban, were associated with a significant reduction of intracranial bleedings [4]. A very recent meta-analysis including 28135 AF elderly patients (≥ 75 years) demonstrated that DOACs were associated with a significant reduction in stroke/systemic embolism and, with the exception of rivaroxaban, with a significant reduction of intracranial bleeding events, with apixaban showing the best combination of efficacy and safety in these older patients [5].…”

Prognosis in Patients Who were Diagnosed as Having Stroke, Using Warfarin, and Aged Over Eighty Years: A Clinical Observation

“…In addition, the profile of risk factors varies depending on age. Older individuals (especially ≥75 years) are at great risk for atrial fibrillation (AF) and AF-associated cardioembolic ischemic stroke (3). Stroke risk associated with AF has been reported as 1.5% between the ages of 50 and 59 years and 23.5% between 80 and 89 years (4,5,6,7,8).…”