Antithrombotic treatment in elderly patients with atrial fibrillation

The problem of underdosing with direct-acting oral anticoagulants in elderly patients with nonvalvular atrial fibrillation

Unless contraindicated, anticoagulant therapy should be prescribed to elderly patients with atrial fibrillation. Direct-acting oral anticoagulants (DOACs) are superior to vitamin K antagonists for preventing stroke. This, together with their higher net clinical benefit, makes DOACs the treatment of choice in this population. However, due to the concerns about bleeding and the need for dose adjustment based on clinical variables, underdosing of DOACs is common and the risk of stroke high. Drugs with more easily adjusted doses are likely associated with a lower risk of dosing errors and, therefore, a greater protective effect. Correct dosing can ensure a maximal net benefit of DOACs in elderly patients with atrial fibrillation.

Age-Related Differences in the Clinical Characteristics and Treatment of Elderly Patients With Atrial Fibrillation in Japan - Insight From the ANAFIE (All Nippon AF In Elderly) Registry

BACKGROUND

Atrial fibrillation (AF) is increasing as the global population ages. Elderly AF patients (≥75 years) have a worse prognosis than younger patients, and effective management is often difficult due to multiple comorbidities. This analysis examined the age-related differences in clinical characteristics and treatment in real-world elderly Japanese AF patients.Methods and Results:The ANAFIE Registry is a multicenter, prospective, observational registry of 32,726 non-valvular AF patients aged ≥75 years. The present study assessed the age-related differences in baseline clinical status and anticoagulant therapy between age groups 75-<80, 80-<85, 85-<90, and ≥90 years. The prevalence of persistent or permanent AF increased, and that of paroxysmal AF decreased, with increasing age (trend P<0.0001). The risk of stroke, based on CHADS₂and CHA₂DS₂-VASc scores, and bleeding, based on HAS-BLED score, increased with age. Both warfarin and apixaban were used more often as age increased (trend P<0.0001, for each), while other anticoagulants were used less. Anticoagulant doses were significantly lower in older patients.

CONCLUSIONS

Permanent/persistent AF, comorbidities, and cardiovascular and bleeding risk all increased significantly with age. Furthermore, use of warfarin and apixaban increased with age, accompanied by a decrease in other oral anticoagulant usage.

Acute kidney injury is linked to higher mortality in elderly hospitalized patients with non-valvular atrial fibrillation

AIM

Renal insufficiency is associated with medical complications in patients with non-valvular atrial fibrillation (NVAF). However, data for elderly patients are scarce. Thus, the main objectives of the present study were to analyze the characteristics of elderly patients with NVAF and acute or chronic renal disease, describe their management in real-life conditions, and detect factors associated with complications.

METHODS

The NONAVASC registry includes patients > 75 years with NVAF, hospitalized by any cause in 64 Spanish Internal Medicine departments. Patients were categorized into acute kidney injury (AKI), chronic kidney disease (CKD) or preserved renal function (PRF). All variables associated with in-hospital mortality with P < 0.10 in univariate analysis were included to develop a multivariate logistic-regression model.

RESULTS

The study included 804 patients (53.9% women), 352 (43.8%) of whom met diagnostic criteria for CKD. AKI was detected in 119 (14.8%) patients. AKI was associated with greater length of stay, higher mortality and an increased rate of patient transfer to nursing homes. After logistic-regression analysis, we found an association between mortality and AKI (OR 2.4, 95% CI 1.03-5.53; P = 0.045). The increase in creatinine values (OR 1.8, 95% CI 1.19-2.73; P = 0.005) and the decrease in albumin values (OR 2.0, 95% CI 1.05-3.73; P = 0.033) were also linked to mortality.

CONCLUSIONS

Our study shows the relationship between AKI and creatinine value increase and a higher mortality in elderly patients with NVAF. In light of our findings, the detection of renal function impairment in these patients should alert physicians and consider them as high-risk patients.

Adherence to recommendations of the Therapeutic Positioning Report about treatment with oral anticoagulants in elderly patients with atrial fibrillation. The ESPARTA study

BACKGROUND AND OBJECTIVE

To evaluate the adherence to the recommendations in clinical practice performed by the Therapeutic Positioning Report (TPR) of the Spanish Agency of Medicines and Sanitary Products about the treatment with oral anticoagulants in patients aged≥75 years old with nonvalvular atrial fibrillation (NVAF) treated in Internal Medicine departments in Spain.

PATIENTS AND METHODS

Observational, cross-sectional and multicenter study in which 837 patients aged≥75 years old with NVAF, with stable treatment with oral anticoagulants at least 3 months before inclusion, and that had started treatment with oral anticoagulants before the inclusion period were included.

RESULTS

Mean age was 83.0±5.0 years old, mean CHADS₂ score 3.2±1.2, mean CHA₂DS₂-VASc score 5.0±1.4, and mean HAS-BLED score 2.1±0.9. A percentage of 70.8 of patients were treated with vitamin K antagonists (VKA) and the rest of patients with direct oral anticoagulants (DOACs). A percentage of 65.6 of patients treated with VKA did not follow the recommendations made by the TPR compared with 43.0% of patients treated with DOACs (P<.0001). In the case of VKA, the main reason for being considered as not appropriate according to the TPR was having poor control of anticoagulation and not switching to DOACs, whereas in the case of DOACs, it was not receiving the adequate dose according to the TPR.

CONCLUSIONS

In a high proportion of anticoagulated elderly patients with NVAF in Spain, the recommendations performed by the TPR are not followed, particularly with VKA, since patients are not switched to DOACs despite time in therapeutic range.

Antithrombotic treatment and characteristics of elderly patients with non-valvular atrial fibrillation hospitalized at Internal Medicine departments. NONAVASC registry

BACKGROUND AND OBJETIVES

The prevalence of non-valvular atrial fibrillation (NVAF) increases with the patient's age and is associated with high morbi-mortality rates. The main goal of this study was to describe the characteristics of hospitalized elderly patients with NVAF and to identify the clinical and functional factors which determine the use of different antithrombotic strategies.

PATIENTS AND METHODS

Observational, prospective, multicentre study carried out on patients with NVAF over the age of 75, who had been admitted for any medical condition to Internal Medicine departments.

RESULTS

We evaluated 804 patients with a mean age of 85 years (range 75-101), of which 53.9% were females. The prevalence of risk factors and cardiovascular disease was high: hypertension (87.6%), heart failure (65.4%), ischemic cardiomyopathy (24.4%), cerebrovascular disease (22.4%) and chronic kidney disease (45%). Among those cases with previous diagnoses of NVAF, antithrombotic treatment was prescribed in 86.2% of patients: anticoagulants (59.7%), antiplatelet medication (17.8%) and double therapy (8.7%). The factors associated with the use of antithrombotic treatment were history of acute coronary syndrome and atrial fibrillation progression longer than one year. Older age, atrial fibrillation for less than one year, higher HAS-BLED scores and severe cognitive impairment were associated with the use of anti-platelet drugs. Permanent atrial fibrillation favoured the use of anticoagulants.

CONCLUSIONS

Hospitalized patients older than 75 years old with NVAF showed numerous comorbidities. The percentage of anticoagulation was small and 18% received only anti-platelet therapy. The patient's age, atrial fibrillation's progression time and the severity of the cognitive impairment influenced this therapy choice.

High rate of mortality in Spanish community-dwelling population aged 85 with atrial fibrillation after three years of follow-up: The Octabaix study

AIM

To assess the possible association between three-year global mortality and atrial fibrillation (AF) in 328 community-dwelling participants aged 85 at baseline.

METHODS

Sociodemographic data, comorbidity and geriatric assessment tools, thromboembolic risk, and AF therapy were assessed. We compared the patients who survived with those who died.

RESULTS

At baseline, 41 (12.5%) of participants had permanent AF, and 13 of them died (31.7%) after the three-year follow-up period compared with 44 (15.3%) of the rest of cohort (P = 0.01). Cox regression analysis identified two significant clinical variables as independent predictors of three-year risk of global mortality: Lawton Index (hazard ratio 0.82, 95% confidence interval 0.75-0.91) and AF (hazard ratio 1.90, 95% confidence interval 1.01-3.56). None of the other of variables evaluated showed predictive value of global mortality in the AF patients.

CONCLUSION

In oldest old community-dwelling participants, AF is an independent risk factor for global mortality after a three-year follow-up period.

Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach

BACKGROUND

Atrial fibrillation (AF) in the elderly is a complex condition. It has a direct impact on the underuse of antithrombotic therapy reported in this population.

DISCUSSION

All patients aged ≥75 years with AF have an individual yearly risk of stroke >4 %. However, the risk of hemorrhage is also increased. Moreover, in this population it is common the presence of other comorbidities, cognitive disorders, risk of falls and polymedication. This may lead to an underuse of anticoagulant therapy. Direct oral anticoagulants (DOACs) are at least as effective as conventional therapy, but with lesser risk of intracranial hemorrhage. The simplification of treatment with these drugs may be an advantage in patients with cognitive impairment. The great majority of elderly patients with AF should receive anticoagulant therapy, unless an unequivocal contraindication. DOACs may be the drugs of choice in many elderly patients with AF. In this manuscript, the available evidence about the management of anticoagulation in elderly patients with AF is reviewed. In addition, specific practical recommendations about different controversial issues (i.e. patients with anemia, thrombocytopenia, risk of gastrointestinal bleeding, renal dysfunction, cognitive impairment, risk of falls, polymedication, frailty, etc.) are provided.