[Oral anticogulation for non-valvular atrial fibrilation in the elderly]

[Femoral neuropathy: Haematoma in iliac muscle and a lumbar vertebral fracture]

75-year-old patient with a history of acenocumarol anticoagulated atrial fibrillation, which shows pain, functional impotence and right lower limb paresthesias after fall. Studies evidenc evertebral fracture L5 and haematoma on right iliac muscle, proceeding to surgical drainage, suspension of acenocumarol, and onset of apixaban. After treatment persisted femoral neuropathy, which not allowed complete functional recovery. DISCUSSION: Femoral neuropathy as possible cause of compressive hematoma over iliopsoas muscle or secundary to lumbar canal stenosis and contact with L4 root. In both of the misit posible to observe weakness of proximal lower limb musculature. Haematoma was suspected due to lower back pain, flank mass and hypovolemia. Handlingis based on the severity of the symptomatology, from conservative to surgical drainage to reduce sequelae and bleeding complications. Apixaban has shown a higher safety profile. Stabilization of lumbar fracture allowed partial functional recovery.

Pharmaceutical intervention after evaluation of the risk of ictus in elderly patients institutionalized with atrial fibrillation

Objectives

To evaluate the risk of having a stroke and the risk of bleeding in institutionalized patients with atrial fibrillation. Atrial fibrillation is a common cardiac arrhythmia associated with increased morbidity and mortality. It is necessary to develop pharmacotherapy plans to minimize the risk.

Design

A prospective study.

Setting

Institutionalized patients.

Participants

Inclusion criteria were: patients diagnosed with atrial fibrillation, with or without treatment for the prevention of stroke.

Main outcome measures

The evaluation of the CHA2DS2-VASc criteria was performed. The risk of hemorrhage was assessed using the HAS-BLED scale, based on the risk factors associated with the probability of bleeding.

Results

We included 53 patients (86.4 ± 6.4 years, 30.2% men). Of these, 37 (69.8%) were correctly anticoagulated. Of the remaining, 5 patients (31.2%) did not have any type of anticoagulant or antiaggregant treatment and 11 (68.7%) were treated with antiaggregant alone. The pharmaceutical intervention was performed in patients who did not meet stroke criteria. Of the untreated patients: two died before the intervention, two were recommended to be referred to cardiology and in one there was no intervention because of very advanced age. In the antiaggregant patients, it was decided not to modify the treatment. The reasons were: high risk of bleeding, very advanced age, advanced dementia or terminal illness, moderate risk of stroke, and clotting factor deficiency.

Conclusions

The risk of stroke in elderly patients with atrial fibrillation is high, so it is important to control the risk factors.

[Making balances between the risks and benefits of pharmacological treatment in dementia, chronic pain and anticoagulation in elderly persons]

In dementia, specific drugs and psychotropic drugs used for psychotic and behavioral symptoms have limited efficacy. Adverse effects may be important given the age and comorbidity of the patients. It is necessary, frequently, its withdrawal, planned together with the family, monitoring the response and offering non-pharmacological treatment alternatives. Chronic pain is suffered by 25-76% of the elderly who live in a community and is more frequent in women. The treatment is multidisciplinary, establishing realistic objectives, individualizing it, starting with lower doses of drugs and continuously reevaluating to control side effects and to get the correct level of analgesia. The prevalence of atrial fibrillation increases with age and is underdiagnosed. ACO is recommended with dicoumarin or direct oral anticoagulants not antagonists of vitamin K, in patients with AF older than 65 years unless contraindicated, to reduce embolic risk, confirming subgroup analyzes similar efficacy in prevention of stroke.

[Oral anticoagulation therapy in the elderly population with atrial fibrillation. A review article]

Aging is an important risk factor for patients with atrial fibrillation. The estimated prevalence of atrial fibrillation in patients aged ≥80 years is 9-10%, and is associated with a four to five fold increased risk of embolic stroke, and with an estimated increased stroke risk of 1.45-fold per decade in aging. Older age is also associated with an increased risk of major bleeding with oral anticoagulant therapy. This review will focus on the role of oral anticoagulation with new oral anticoagulants, non-vitamin K antagonist in populations with common comorbid conditions, including age, chronic kidney disease, coronary artery disease, on multiple medication, and frailty. In patients 75 years and older, randomised trials have shown new oral anticoagulants to be as effective as warfarin, or in some cases superior, with an overall better safety profile, consistently reducing rates of intracranial haemorrhages. Prior to considering oral anticoagulant therapy in an elderly frail patient, a comprehensive assessment should be performed to include the risks and benefits, stroke risk, baseline kidney function, cognitive status, mobility and fall risk, multiple medication, nutritional status assessment, and life expectancy.

Anticoagulation in atrial fibrillation: NOAC prescribing in primary health care

Background Few studies assess the use of non-vitamin K antagonist oral anticoagulants (NOACs) in daily practice for the prevention of thromboembolic complications associated to nonvalvular atrial fibrillation (AF). Objectives Describe NOACs' use and analyze its prescribing pattern. Evaluate possible factors associated to adverse events (AEs) and the applicability of prescription support forms. Methods We included patients with AF treated with a NOAC during 2014 in three primary healthcare centers in Barcelona, Spain. Demographic and clinical data was collected, as well as embolic and bleeding risk and reported AEs. Results A total of 101 patients were included, with a median age of 75 years. The NOACs most frequently prescribed were dabigatran and rivaroxaban. An 87.2% of the patients were receiving the recommended dosage. A potential bleeding risk was present in 47% of the subjects. Ten AEs were reported, of which eight hemorrhages. Patients who presented an AE were >65 years and had a higher proportion of concomitant treatment and/or co-morbidities that could prompt to bleeding (p < 0.001). Conclusions Current treatment practice is according to regulatory agencies' recommendations. Close monitoring is especially needed in patients >65 years and at higher risk of bleeding. Prescription support forms help good prescribing and identifying potential individuals at high risk of AEs.