Reasons for and consequences of vitamin K antagonist discontinuation in very elderly patients with non‐valvular atrial fibrillation

Abstract

Essentials• Anticoagulation in the elderly is still a challenge and suspension of warfarin is common.• This is an observational study reporting reasons and consequences of warfarin suspension.• Vascular disease, age, time in therapeutic range, and bleedings are associated with suspension.• After suspension for bleeding or frailty, patients remain at high-risk of death or complications.Summary. Background: Anticoagulation in elderly patients with non-valvular atrial fibrillation (NVAF) is still a challenge, and discontinuation of warfarin is common. The aim of this study was to analyze the aspects related to warfarin discontinuation in a real-world population. Methods: This was an observational cohort study on very elderly NVAF patients naive to warfarin therapy (VENPAF). The included subjects were aged at least 80 years, and started using warfarin after a diagnosis of NVAF. Warfarin discontinuation was assessed, and the reason reported for discontinuation, the person who decided to stop treatment, subsequent antithrombotic therapy and mortality, ischemic and bleeding events were collected. Results: Over a period of 5 years, warfarin was discontinued in 148 of 798 patients.Despite similar CHA 2 DS 2 -VASc scores, the frequencies of thromboembolic and major bleeding events were significantly higher (P = 0.01 and P = 0.001, respectively) and the time in therapeutic range (TTR) was significantly lower (P < 0.001) in patients who discontinued warfarin. Independent risk factors for warfarin discontinuation were vascular disease (hazard ratio [HR] 2.5, P < 0.001), age ≥ 85 years (HR 1.4, P = 0.04), TTR < 60% (HR 1.8, P = 0.001), and bleeding events (HR 2.3, P < 0.001). The main reasons for warfarin discontinuation were physicianperceived frailty or low life-expectancy (45.9%), bleeding complications (19.6%), and sinus rhythm restoration (16.9%). Event and death rates were very high, especially in frail patients and in those with bleeding complications. Conclusions: Warfarin discontinuation is frequent in very elderly patients, and is associated with increased risks of death and adverse events. Identification of elderly patients who are at high risk of bleeding and the poor quality of anticoagulation during warfarin are still unsolved clinical problems.

Dabigatran etexilate: appropriate use in patients with chronic kidney disease and in the elderly patients

“…Advanced age per se, physician's perceived high risk of age-related and fall-related bleeding, and difficulties in monitoring warfarin-based anticoagulant therapy have been reported among the main factors accounting for underprescription of anticoagulant therapy in older patients with AF [41,[43][44][45]. Although several studies suggest that advanced age itself should not prevent prescription of oral anticoagulants in the elderly patients [46][47][48], under-prescription of anticoagulants among the oldest patients remains a common clinical practice in several contemporary medical settings [15,45]. Among the perceived or actual barriers to warfarin use in older subjects with AF, the predisposition to falls represents an important issue [49].…”

Stroke Prevention in Atrial Fibrillation in the Very Elderly: Anticoagulant Therapy Is No Longer a Sin

“…It is well established that older individuals with atrial fibrillation (AF) are less likely to receive oral anticoagulant (OAC) therapy compared with their younger counterparts, and when treated with vitamin K antagonists (VKAs), there is a relatively high rate of discontinuation resulting in a high rate of stroke or death . This undertreatment of the very elderly represents a paradox because older patients are at higher risk of stroke and are more likely to need anticoagulant therapy compared with younger patients .…”

“…There are many reasons for the undertreatment of AF in the elderly including physician‐related factors, patient‐related factors, and the practical aspects of therapy . An overriding concern, however, is the fear of putting the patient at risk for major bleeding as a result of anticoagulant therapy, while the fear of leaving the patient open to stroke is of lesser concern . This is sometimes expressed as the fear of creating a sin of commission versus a sin of omission (by doing something we should not do versus not doing something we should do) .…”

Optimizing stroke prevention in elderly patients with atrial fibrillation

“…In this issue of the Journal of Thrombosis and Haemostasis , Bertozzo et al . report an observational cohort study on very elderly non‐valvular AFpatients naive to warfarin treatment. This cohort included newly anticoagulated AF patients aged >80 years, where, over a period of 5 years, 19% (148/798) of elderly patients discontinued warfarin treatment.…”

“…Unsurprisingly, warfarin discontinuation in the study by Bertozzo et al . was associated with increased risks of death and adverse events. Elderly AF patients are at high risk for fatal and disabling stroke, and non‐adherence to thromboprophylaxis clearly leads to worse outcomes .…”