Review Article
Thromboembolic Prevention in Frail Elderly Patients With Atrial Fibrillation: A Practical Algorithm

https://doi.org/10.1016/j.jamda.2014.12.008Get rights and content

Abstract

Atrial fibrillation is a common condition in the elderly, and the incidence of thromboembolic events secondary to atrial fibrillation increases with age. Antithrombotic therapy effectively prevents stroke and systemic embolism but also exposes patients to the risk of bleeding. Because the risk of bleeding also increases with age, clinicians tend to withhold anticoagulation in the elderly. Anticoagulation is particularly complex in the frail elderly patient, who presents additional risk factors affecting both efficacy and safety of thromboembolic prevention. The main clinical trials rarely include frail elderly patients and, consequently, the guidelines do not provide guidance for their management. In the absence of clear indications for this class of patients, we identified some areas that should be taken into account both before starting and when discontinuing anticoagulation: comorbidities, polypharmacotherapy, adherence, cognitive impairment, mobility and monitoring barriers, nutritional status and swallowing disorders, risk of falls, and reduced life expectancy. We also suggest a multidimensional algorithm covering both a standard ischemic and bleeding risk assessment and an additional anticoagulation-focused frailty assessment. This is of particular relevance given the recent introduction of the oral direct inhibitors, as they are likely to widen the treatment options for the frail elderly. Depending on which aspect of frailty is present, anticoagulation can now be tailored accordingly.

Section snippets

Stroke Risk in Elderly Patients With Atrial Fibrillation and Efficacy of Thromboembolic Prevention in the Elderly

The ischemic stroke rate among patients with nonvalvular AF averages 5% per year, 2 to 7 times the rate of those in sinus rhythm, depending on the risk score.6 The elderly are particularly vulnerable to stroke when AF is present. In a wide population of AF patients, the attributable risk of stroke increased with age, rising from 1.5% for those aged 50–59 years to 23.5% for those aged 80–89 years (P < .01).7

The most accurate tools to assess thromboembolic risk in AF are the CHADS2 (Congestive

Bleeding Risk in Elderly Patients and Safety of Thromboembolic Prevention

All patients on anticoagulant therapy are exposed to the risk of bleeding, but increasing age raises the risk of serious bleeding.16 This is underlined by the fact that both tools for the assessment of bleeding risk include older age as a risk factor (≥65 years for the HAS-BLED and ≥75 years for the HEMORR2HAGES). Of particular concern are intracranial hemorrhages, which are 2.5 times more common among people aged ≥85 years17 and account for almost 90% of deaths from anticoagulant- associated

The Role of the New Oral Anticoagulants in Thromboembolic Prevention in the Elderly

In the last few years, a new class of anticoagulant drugs has been tested in 4 large randomized phase III trials vs VKAs for nonvalvular AF.21, 22, 23, 24 Three direct factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban) and a factor IIa inhibitor (dabigatran) were found either noninferior or superior to VKAs in stroke prevention for AF patients. Subgroup analyses in elderly patients (≥75 years) are available.25 Of note, apixaban and high dose dabigatran (150 mg), in patients ≥75, were

Oral Anticoagulation in the Frail Elderly Patient

General definitions of frailty cannot be easily applied to the field of anticoagulation, and AF guidelines do not provide direct guidance for the management of elderly patients with characteristics of frailty.3, 15 Thromboembolic prevention management is, therefore, often inadequate in the elderly compared with their younger counterparts.26 Some argue that physicians are too aggressive, prescribing standard anticoagulation even to patients who may not benefit from it, often because of low

Anticoagulant Focused Geriatric Assessment

In order to assess frailty, elderly patients with AF should undergo a multidimensional assessment, including the areas discussed above. This should result in a ‘clearer view’ of a patient and is likely to help clinicians to take more balanced decisions with regards to anticoagulant therapy. First, identification of frail elderly patients will help doctors to use caution with them, to correct their reversible risk factors, and to follow-up more regularly. Second, a tailored anticoagulation

Conclusions

Elderly patients with AF are at high risk of both stroke and bleeding. As a result, clinicians are often uncertain about thromboembolic prevention, with an overall underuse of oral anticoagulation. A multidimensional anticoagulation-focused tool to identify frail elderly patients can help clinicians to take balanced decisions on anticoagulation. Awareness of the risk, correction of reversible risk factors, and tailored oral anticoagulation are at present the best tools to improve stroke

Acknowledgments

The authors thank Ms Caroline Fahmy and Dr Giacomo Zoppellaro for their proofreading and graphic help.

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    The authors declare no conflicts of interest.

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