Effects of Oral Anticoagulants on Patients With Atrial Fibrillation Aged 90 Years and Older: Comparison Among Direct Oral Anticoagulant, Warfarin Anticoagulant, and Nonanticoagulation

Antithrombotic Therapy in Elderly Patients with Acute Coronary Syndromes

The treatment of acute coronary syndrome (ACS) in elderly patients continues to be a challenge because of the characteS.G.B.ristics of this population and the lack of data and specific recommendations. This review summarizes the current evidence about critical points of oral antithrombotic therapy in elderly patients. To this end, we discuss the peculiarities and differences reported referring to dual antiplatelet therapy (DAPT) in ACS management in elderly patients and what might be the best option considering these population characteristics. Furthermore, we analyze antithrombotic strategies in patients with atrial fibrillation (AF), with a particular focus on those cases that also present coronary artery disease (CAD). It is imperative to deepen our knowledge regarding the management of these challenging patients through real-world data and specifically designed geriatric studies to help resolve the questions remaining in their disease management.

Effect of Edaravone Combined with Anticoagulant Therapy on the Serum hs-CRP, IL-6, and TNF-α Levels and Activity of Daily Living in Patients with Acute Cerebral Infarction

Objective

To explore the effect of edaravone combined with anticoagulant therapy on the serum hs-CRP, IL-6, and TNF-α levels and the activity of daily living (ADL) in patients with acute cerebral infarction (ACI).

Methods

The clinical data of 84 ACI patients treated in our hospital from August 2020 to August 2021 were retrospectively analyzed, and they were divided into the routine group (n = 42) and the combined group (n = 42) according to the order of admission. Both groups were treated with routine clinical treatment, and the combined group was additionally treated with edaravone combined with anticoagulant therapy. Serum samples were collected from both groups after treatment. ELISA was used to detect the serum inflammatory factor levels, and the modified Barthel index score was used to evaluate the ADL of patients.

Results

Compared with the routine group, the combined group achieved obviously lower levels of PMA, CD62p, and serum inflammatory factors after treatment (P < 0.001), higher modified Barthel score after treatment (P < 0.001), lower plasma viscosity, platelet aggregation rate, and plasma fibrinogen level after treatment (P < 0.001), and higher clinical overall efficacy (P < 0.05).

Conclusion

Edaravone combined with anticoagulant therapy is a reliable method to enhance ADL and reduce the inflammatory response of ACI patients. This strategy greatly reduces the platelet-activating factor levels of patients and improves the comprehensive clinical efficacy, and its further research will help to establish a better solution for these patients.

Evaluation of the Effectiveness and Safety of Direct Oral Anticoagulants in Elderly Patients With Nonvalvular Atrial Fibrillation Who Are Not Candidates for Warfarin in Real-World Setting

ABSTRACT

Limited literature has established the role of direct oral anticoagulants (DOAC) for elderly patients with nonvalvular atrial fibrillation who are unsuited for warfarin. Therefore, the objectives of this study were to assess the effectiveness and safety of DOAC use in this vulnerable patient population. This was a retrospective propensity score matching cohort study. Among all patients aged 75+ years who were not candidates for warfarin, we matched those who initiated DOAC between September 2017 and September 2018 with those who did not receive DOAC or warfarin in a 1:1 ratio. Effectiveness outcome was a composite measure of stroke, transient ischemic attack, and pulmonary embolism. Safety outcome was a composite measure of non-trauma-related intracranial hemorrhage and gastrointestinal bleed. Unless patients died or lost membership, follow-up period for the effectiveness outcome was until the end of 2019, whereas the safety outcome was for a period up to 1 year. Conditional logistic regression was used to analyze both outcomes. We identified 7818 patients who met the inclusion criteria and started DOAC, which matched to 7818 patients who did not receive anticoagulants. The mean age was 82.3 ± 5.1 years, and 51.5% male. The DOAC group had a lower hazard ratio of 0.37 (confidence interval, 0.24-0.57; P < 0.01) for composite effectiveness outcomes, whereas no difference in the composite safety outcome (hazard ratio, 0.91; confidence interval, 0.65-1.25; P = 0.55) when compared with matched control. In conclusion, DOAC was found to be effective in preventing thromboembolic events in patients aged 75+ years with nonvalvular atrial fibrillation who were not eligible for warfarin.

Update on drug interactions with non-vitamin-K-antagonist oral anticoagulants for stroke prevention in elderly patients

Introduction: We update the knowledge, since the last review in 2017, about drug-drug interactions (DDI) of non-vitamin-K-antagonist oral anticoagulants (NOAC) in patients ≥75 years.Areas covered: The literature was searched for: 'dabigatran,' 'rivaroxaban,' 'edoxaban,' or 'apixaban' and drugs, affecting platelet function, CYP3A4-, CYP2C9-, or P-Gp-activity. Pharmacodynamic DDI of NOAC with drugs affecting platelet function like nonsteroidal anti-inflammatory drugs and antiplatelet agents occur most frequently. Pharmacokinetic DDI with NOAC were found for 37 of 117 drugs. Reports about DDI with NOAC were found for 51% of P-gp-affecting, 38% for CYP2C9-affecting and 27% for CYP3A4-affecting drugs. Reports about DDI of cardiovascular drugs with NOAC were the most prevalent, followed by anti-infective and nervous system drugs. NOAC plasma levels were measured in retrospective and cohort studies and were associated with concomitant medication. Reports about DDI of NOAC were found in 71 patients ≥75 years.Expert opinion: The knowledge about DDI of NOAC in elderly patients is very limited. Studies should be carried out to investigate the role of drugs potentially interacting with NOAC, which until now have not been investigated. When studying DDI of NOAC, care should be taken to include elderly patients with impaired renal function and patients on polymedication.

Direct Oral Anticoagulants Versus Vitamin-K Antagonist After PCIs in Patients With AF: A Meta-analysis of Cardiac Ischemic Events

BACKGROUND

Clinical trials have assessed the effect of direct oral antagonists (DOACs) in patients with atrial fibrillation (AF) after percutaneous coronary interventions (PCI). Studies were designed to test the effect on bleeding incidence, but concerns related to safety on ischemic events remain.

METHODS

We performed a meta-analysis with currently available studies involving DOACs versus Vitamin-K antagonist (VKA) in patients with AF after PCI. The primary endpoint was the incidence of cardiac ischemic events, including myocardial infarction and stent thrombosis. Secondary endpoints were the incidence of stroke, all-cause mortality, and major bleeding.

RESULTS

Eleven thousand twenty-three patients were included in the analysis: 5510 receiving DOACs and 5513 VKA. A total of 190 cases of myocardial infarction were registered in patients treated with DOACs and 177 in patients on VKA, and no statistical difference was noted [relative risk (RR): 1.07 95% confidence interval (CI) 0.88-1.31]. The incidence of stent thrombosis was very low with no differences between both treatment strategies (RR: 1.14 95% CI 0.76-1.71). The incidence of cardiac ischemic events was the same in patients receiving DOACs or VKA (HR 1.09 95% CI 0.91-1.30). No differences were observed in the incidence of stroke (RR: 0.86 95% CI 0.61-1.23) or mortality (RR: 1.09, 95% CI 0.90-1.31). Treatment with DOACs was associated with 34% reduction in major bleeding (RR: 0.66, 95% CI 0.54-0.81).

CONCLUSIONS

Treatment with DOACs in patients with AF after a PCI do not increase the risk of cardiac ischemic events, stroke, or death and reduce the incidence of major bleeding by 34% as compared with VKA.

Non-vitamin K antagonist oral anticoagulants in very elderly east Asians with atrial fibrillation: A nationwide population-based study

BACKGROUND

The evidence of effectiveness and safety of the non-vitamin K antagonist oral anticoagulants (NOACs) among elderly East Asians is limited.

OBJECTIVES

We aimed to describe the effectiveness and safety outcomes associated with NOACs and warfarin among elderly Koreans aged ≥80 years.

METHODS

Using the Korean Health Insurance Review and Assessment service database, patients with atrial fibrillation (AF) who were naïve to index oral anticoagulant between 2015 and 2017 were included in this study (20,573 for NOACs and 4086 for warfarin). Two treatment groups were balanced using the inverse probability of treatment weighting (IPTW) method. The clinical outcomes including ischemic stroke, major bleeding including intracranial hemorrhage (ICH) and gastrointestinal bleeding (GIB), and a composite of these outcomes were evaluated.

RESULTS

Compared to warfarin, NOACs were associated with lower risks of ischemic stroke (hazard ratio 0.74 [95% confidence interval 0.62-0.89]), and composite outcome (0.78 [0.69-0.90]). NOACs showed nonsignificant trends towards to lower risks of GIB and major bleeding than warfarin. The risk of ICH of NOAC group was comparable with the warfarin group. Among NOACs, apixaban and edoxaban showed better composite outcomes than warfarin. Among the clinical outcomes, only ischemic stroke and the composite outcome had a significant interaction with age subgroups (80-89 years and ≥90 years, P-for-interaction = .097 and .040, respectively).

CONCLUSION

NOACs were associated with lower risks of ischemic stroke and the composite outcome (ischemic stroke and major bleeding) compared to warfarin in elderly East Asians. Physicians should be more confident in prescribing NOACs to elderly East Asians with AF.

Clinical Outcomes of Direct Oral Anticoagulants and Warfarin in Japanese Patients with Atrial Fibrillation Aged ≥ 85 Years: A Single-Center Observational Study

Background

Increasing age is associated with an increase in stroke in patients with nonvalvular atrial fibrillation (NVAF). Elderly patients have several comorbidities and increased bleeding risk.

Objective

The aim of this study was to evaluate the clinical outcomes of Japanese patients with NVAF aged ≥ 85 years who were treated with direct oral anticoagulants (DOACs) or warfarin.

Methods

We retrospectively studied the records of 358 patients with NVAF aged ≥ 85 years who had taken DOACs or warfarin between 2014 and 2018. The primary endpoints were the first occurrences of thromboembolic and bleeding events and death. The secondary endpoint was the discontinuation of oral anticoagulation (OAC) therapy.

Results

During a median follow-up period of 17 months, 24 patients died. The incidence (per 100 patient-years [PY]) of thromboembolic events was 1.8 in patients treated with DOACs and 2.2 in those treated with warfarin (adjusted subdistribution hazard ratio [SHR] 0.69; 95% confidence interval [CI] 0.23–2.12 in a competing model), and the incidence of major bleeding events was 3.1 and 4.2 in patients treated with DOACs and warfarin, respectively (adjusted SHR 0.95; 95% CI 0.32–2.86). The most common cause of bleeding events was gastrointestinal bleeding. A total of 33 patients permanently discontinued OAC therapy, at a median age of 89 years and with no differences between DOACs and warfarin. The most common reason for discontinuing OAC therapy was bleeding events.

Conclusion

Our results revealed that the incidences of thromboembolism and major bleeding among patients with NVAF aged ≥ 85 years were similar for those treated with DOACs and those treated with warfarin. Approximately 10% of patients permanently discontinued OAC therapy.

Electronic supplementary material

The online version of this article (10.1007/s40801-020-00209-4) contains supplementary material, which is available to authorized users.