Review ArticleThromboembolic Prevention in Frail Elderly Patients With Atrial Fibrillation: A Practical Algorithm
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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Cited by (38)
Frailty and outcomes in older adults with non-valvular atrial fibrillation from the ANAFIE registry
2022, Archives of Gerontology and GeriatricsCitation Excerpt :Villani et al., 2018; Wilkinson, Todd & Clegg, 2019) Frail older adults with NVAF tend to be undertreated with oral anticoagulants (OACs), and age seems to be the main determining factor for this therapeutic choice because of the increased bleeding risk with age. ( Granziera, Cohen & Nante, 2015; Tulner, Van Campen & Kuper, 2010) Anticoagulation in frail NVAF patients may be more complex because of the presence of factors affecting anticoagulation safety, such as comorbid conditions (heart failure, dementia, chronic respiratory conditions, diabetes, and chronic kidney disease), risk of falls, malnutrition, and polypharmacy. ( Granziera et al., 2015)
Anticoagulants and Antiplatelet Drugs
2022, Comprehensive PharmacologyUse of oral anticoagulants in complex clinical situations with atrial fibrillation
2018, Medicina ClinicaOral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence
2017, European Journal of Internal MedicineCitation Excerpt :It is likely that OAT may sometimes be perceived by physicians as “futile” or potentially harmful in patients with short life-expectancy. Unfortunately, although some theoretical tools have been recently suggested to address frailty in this context [39], by now there are not validated and widely acknowledged methods to identify those older patients who, in reason of their poor general health and/or functional status, are expected not to derive a net clinical benefit from anticoagulation, and should therefore not be prescribed OAT. Selection of the “right” anticoagulant drug for stroke prevention in the elderly should be based on a global evaluation of patient's characteristics, including age, comorbidity, kidney function, overall and gastrointestinal bleeding risks, ischemic or hemorrhagic stroke history, patient's preference for low pill burden and, obviously, costs [39,61,107] (Fig. 1).
Risk of cardiovascular disease morbidity and mortality in frail and pre-frail older adults: Results from a meta-analysis and exploratory meta-regression analysis
2017, Ageing Research ReviewsCitation Excerpt :Very little is known if the treatment of frailty per se could be preventive from a cardiovascular point of view. Even if drugs commonly used for the prevention of CVD may be poorly applicable for very frail older subjects (Granziera et al., 2015; Stone et al., 2014), a recent study reported that strict adherence to guidelines for cardiovascular drugs could delay overall mortality in older adults affected by several chronic conditions (Tinetti et al., 2015). For example, recent evidence suggests that the level of frailty among community-living older people does not interact with the efficacy of antihypertensive treatment (Bulpitt et al., 2012).
Use of Frailty in Deciding Clinical Treatment Goals for Chronic Disease in Elderly Patients in the Community
2016, Journal of the American Medical Directors Association
The authors declare no conflicts of interest.