Use and Prescription of Direct Oral Anticoagulants in Older and Frail Patients with Atrial Fibrillation: A Multidisciplinary Consensus Document

Abstract

In the last twelve years the clinical management of patients with atrial fibrillation has been revolutionised by the introduction of direct oral anticoagulants. Despite the large amount of evidence produced, some populations remain relatively poorly explored regarding the effectiveness and safety of direct oral anticoagulants, such as the oldest and/or frailest individuals. Frailty is clinical syndrome characterized by a reduction of functions and physiological reserves which results in individuals having higher vulnerability. While current evidence underlines a relationship between atrial fibrillation and frailty, particularly in determining a higher risk of adverse outcomes, data regarding effectiveness and safety of direct oral anticoagulants in frailty atrial fibrillation patients are still lacking, leaving uncertainty about how to guide prescription in this specific subgroup. On these premises, this multidisciplinary consensus document explains why it would be useful to integrate the clinical evaluation performed through comprehensive geriatric assessment to gather further elements to guide prescription of direct oral anticoagulants in such a high-risk group of patients.

Clinical Complexity Domains, Anticoagulation, and Outcomes in Patients with Atrial Fibrillation: A Report from the GLORIA-AF Registry Phase II and III

“…29 Renal disease has been also described as a main driver of OAC underuse as well as major outcomes among AF patients, 31,32 and history of bleeding represent a common concern when prescribing antithrombotic. Undertreatment and lower persistence, therefore, may reflect the lack of data regarding safety of anticoagulants in frail complex patients, 33,34 which were consistently under-represented in randomized controlled trials, even if NOACs have already been proved to be a safer alternative compared to VKA. 3 On the other hand, we show how clinical complexity can impact prognosis, although with some differences among different domains, and how the concurrence of more than one condition can entail a worse prognosis.…”

Effectiveness and Safety of Edoxaban Compared With Apixaban in Elderly Patients With Nonvalvular Atrial Fibrillation: A Real-World Population-Based Cohort Study

“…7 A shared-decision making approach is encouraged between physicians and patients to individualize and optimize OAC therapy strategies (including dosage regimen) based on their comorbidities, comedications, values, and preferences. 7,30,31,37…”

Direct Oral Anticoagulants in Old and Frail Patients with Atrial Fibrillation: The Advantages of an Anticoagulation Service

“…The multidisciplinary consensus documents published by Proietti et al in this issue of the Journal of Personalized Medicine specifically addresses conditions with relatively limited evidence on the use of DOACs such as multimorbidity, polypharmacy, high risk for falling, dementia, frailty, or older age [ 11 ]. The focus is mainly placed on frailty, which has a variable prevalence, probably due to the different definitions used in the related reports and because, regardless of the definition, it has an influence on the risk for adverse outcomes, in particular on bleeding [ 12 ].…”

“…Proietti et al propose an integrated clinical approach involving a multidisciplinary team to face the clinical aspects related to AF in old and frail patients and the use of geriatric comprehensive assessment (GCA) [ 11 ]. Geriatric comprehensive assessment is usually defined as “a multidimensional, multidisciplinary process which identifies medical, social and functional needs and the development of an integrated/coordinated care plan to meet those needs”.…”

“…To complement the comprehensive care proposed by Proietti et al [ 11 ], we would like to focus on the importance of adequate services for the management of the anticoagulant treatment in old and frail patients.…”