High Rate of Anticoagulation Therapy in Oldest Old Subjects With Atrial Fibrillation: The Octabaix Study (original) (raw)
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Oral anticoagulation in octogenarians with atrial fibrillation
International Journal of Cardiology, 2016
Background. Vitamin K antagonists (VKAs) are still largely employed, even in nonvalvular atrial fibrillation (AF). Our aim was to study the clinical profile of octogenarians treated with oral anticoagulation and to study the effect of age on the quality of VKAs anticoagulation. Methods. Data are from a prospective national registry in an adult Spanish population of nonvalvular AF. We included 1637 patients who had been receiving VKAs for at least 6 months before enrolment. Results. Mean age was 73.8 ± 9.4 years. Patients aged > 80 years (N = 429) had a high risk profile with higher risk of stroke and bleeding than younger patients; CHA 2 DS 2-VASc (Cardiac failure, Hypertension, Age > 74, Diabetes, Stroke, Vascular disease, Age 65-74 years, and Sex category) 4.5 ± 1.3 vs. 3.5 ± 1.6, p < 0.001, HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 64 years), Drugs/alcohol concomitantly) 2.4 ± 0.9 vs. 1.9 ± 1.1, p < 0.001. Creatinine clearance was lower in octogenarians than in younger patients (54.3 ± 16.1 ml/min vs. 69.5 ± 23.7 ml/min, p < 0.001) and severe renal disease with creatinine clearance < 30 ml/min was more frequent in octogenarians (5.2% vs. 2.2%, p < 0.001). In patients treated with VKAs (N = 1637), the international normalized ratio values of the 6 months previous to enrollment were similar in all age quartiles, as was the time in the therapeutic range. Conclusion. In this large registry octogenarians with nonvalvular AF had high risk of stroke and bleeding and frequent renal disease. VKAs anticoagulation quality was similar in octogenarians and in younger patients.
Heart Rhythm, 2018
Background: Oral anticoagulation (OAC) is effective in stroke prevention in elderly patients with non-valvular atrial fibrillation (AF), but older patients are also at greater risk of bleeding. Objective: We aimed to examine whether OAC has net clinical benefit (NCB) in elderly patients with AF. Methods: a retrospective cohort study of patients with AF, aged ≥75 years, between 2013 and 2015. Incidence of stroke and intracranial hemorrhage (ICH) were estimated per 100person-years. The NCBs were estimated with respect to time in therapeutic range (TTR) (<60% or ≥60%) and treatment type (warfarin and low or high dose direct oral anticoagulants (DOACs). Results: We included 11,760 patients, of whom 4,982 (42.4%) were treated with OACs; 2,042 (17.4%) with warfarin and 2,940 (25.0%) with DOACs. Among patients treated with warfarin, those who achieved TTR≥60% had lower incidence of stroke (2.54 vs. 5.21, P=0.01), without statistically lower incidence of ICH (0.68 vs. 1.10, P=0.45) and higher NCB (9.78 vs. 6.52) as compared to those with TTR<60%. Among patients treated with DOACs, patients treated with the high dose had statistically similar incidence of stroke (8.40 vs. 9.81, P=0.67), statistically lower incidence of ICH (0.33 vs. 1.20, P=0.02) and higher NCB (4.42 vs. 1.78) compared to the patients treated with the low dose. Conclusion: A large proportion of elderly patients are not treated with OAC. We found that the NCB of OAC in the elderly is positive, with the greatest in elderly patients treated with warfarin with TTR≥60% or high dose of DOACs.
Journal of aging research, 2014
Several studies have reported underprescription of anticoagulants in atrial fibrillation (AF). We conducted an observational study on 142 out of a total of 995 consecutive ≥75 years old patients presenting AF (14%) when admitted in an emergency unit of a general hospital, in search of geriatric characteristics that might be associated with the underprescription of anticoagulation therapy (mostly antivitamin K at the time of the study). The following data was collected from patients presenting AF: medical history including treatment and comorbidities, CHADS2 score, ISAR scale (frailty), Lawton's scale (ADL), GDS scale (mood status), MUST (nutrition), and blood analysis (INR, kidney function, and albumin). Among those patients for who anticoagulation treatment was recommended (73%), only 61% were treated with it. In the group with anticoagulation therapy, the following characteristics were observed more often than in the group without such therapy: a recent (≤6 months) hospitaliza...
Anticoagulant Use for Atrial Fibrillation in the Elderly
Journal of the American Geriatrics Society, 2000
OBJECTIVES: To determine the influence of advanced age on anticoagulant use in subjects with atrial fibrillation and to explore the extent to which risk factors for stroke and contraindications to anticoagulant therapy predict subsequent use. DESIGN: Retrospective cohort study. SETTING: The Veterans Affairs Boston Healthcare System. PARTICIPANTS: A total of 2,217 subjects with nonvalvular atrial fibrillation. MEASUREMENTS: Administrative databases were use to identify subject's age, anticoagulant use, and the presence of a diagnosis of atrial fibrillation, cerebrovascular accident, hypertension, diabetes mellitus, congestive heart failure, or gastrointestinal or cerebral hemorrhage. RESULTS: Unadjusted analysis showed no difference in warfarin use between those aged 75 and older and younger subjects regardless of the presence (33.9% vs 35.7%, P 5.37) or absence (33.4% vs 34.7%, P 5.58) of contraindications to anticoagulant therapy. Multivariate modeling demonstrated a 14% reduction (95% confidence interval (CI) 5 4-22%) in anticoagulant use with each advancing decade of life. Intracranial hemorrhage was a significant deterrent (odds ratio (OR) 5 0.27 95% CI 5 0.06-0.85). History of hypertension (OR 5 2.90, 95% CI 5 2.15-3.89), congestive heart failure (OR 5 1.70, 95% CI 5 1.41-2.04), and cerebrovascular accident (OR 5 1.54, 95% CI 5 1.25-1.89) were significant independent predictors for anticoagulant use. CONCLUSION: Despite consensus guidelines to treat all atrial fibrillation patients aged 75 and older with anticoagulants, advancing age was found to be a deterrent to warfarin use. Better estimates of the risk:benefit ratio for oral anticoagulant therapy in older patients with atrial fibrillation are needed to optimize decision-making.
Journal of geriatric cardiology : JGC, 2016
In elderly patients, especially those older than 80 years, atrial fibrillation (AF) is associated with an almost 25% increased risk of stroke. Stroke prophylaxis with anticoagulants is therefore highly recommended. The prevalence of factors that have been associated with a lower rate of prescription and adherence to anticoagulant therapy in these patients is little known. The objective of this study was to explore the clinical characteristics of elderly subjects, with and without AF, consecutively admitted to an acute geriatric unit, discussing factors that may decrease the persistence on stroke prophylaxis therapy. We also highlight possible strategies to overcome the barriers conditioning the current underuse of oral anticoagulants in this segment of the population. A retrospective observational study was performed on a cohort of elderly patients with and without AF admitted to the Acute Geriatric Unit of San Gerardo Hospital (Monza, Italy). Compared to patients without AF (n = 12...
Internal and Emergency Medicine, 2023
Introduction Direct oral anticoagulants (DOACs) are underused in the elderly, regardless the evidence in their favour in this population. Methods We prospectively enrolled anticoagulant-naïve patients aged ≥ 75 years who started treatment with DOACs for atrial fibrillation (AF) and stratified them in older adults (aged 75-84 years) and extremely older adults (≥ 85 years). Thrombotic and hemorrhagic events were evaluated for 12 months follow-up. Results We enrolled 518 consecutive patients. They were mostly aged 75-84 years (299 patients; 57.7%) vs. ≥ 85 years (219 patients; 42.3%). Extremely older adults showed higher incidence of all the endpoints (systemic cardioembolism [HR 3.25 (95% CI 1.71-6.18)], major bleeding [HR 2.75 (95% CI 1.77-4.27)], and clinically relevant non-major bleeding [HR 2.13 (95% CI 1.17-3.92)]) vs. older adults during the first year after starting anticoagulation. In patients aged ≥ 85 years, no difference in the aforementioned endpoints was found between those receiving on-label vs. off-label DOACs. In the extremely older adults, chronic kidney disease, polypharmacy, use of antipsychotics, and DOAC discontinuation correlated with higher rates of thrombotic events, whereas a history of bleeding, Charlson Index ≥ 6, use of reduced DOAC dose, absence of a caregiver, use of non-steroidal anti-inflammatory drugs (NSAIDs), and HAS-BLED score ≥ 3 were associated with major bleedings. Conclusions Naïve patients aged ≥ 85 who started a DOAC for AF are at higher risk of thrombotic and bleeding events compared to those aged 75-84 years in the first year of therapy. History of bleeding, HAS-BLED score ≥ 3 and use of NSAIDs are associated with higher rates of major bleeding.
Anticoagulation therapy in elderly patients with atrial fibrillation
Journal of Cardiovascular Medicine, 2017
on behalf of the RAFTING Investigators à Background Patients with atrial fibrillation aged 75 years or older have a CHA 2 DS 2 VASc score that dictates oral anticoagulants. We recorded physicians' anticoagulation attitudes in elderly patients with atrial fibrillation and assessed the impact of stroke and bleeding risk.
Oral Anticoagulation in Very Elderly Patients with Atrial Fibrillation - A Nationwide Cohort Study
Circulation, 2018
BACKGROUND: Stroke prevention with oral anticoagulants (OACs) is the cornerstone for the management of atrial fibrillation (AF). However, data about the use of OACs among patients ≥90 years of age are limited. We aimed to investigate the risk of ischemic stroke and intracranial hemorrhage (ICH) and the net clinical benefit of OAC treatment for very elderly patients with AF (≥90 years of age). METHODS: This study used the National Health Insurance Research Database in Taiwan. Risks of ischemic stroke and ICH were compared between 11 064 and 14 658 patients with and without AF ≥90 years of age without antithrombotic therapy from 1996 to 2011. Patients with AF (n=15 756) were divided into 3 groups (no treatment, antiplatelet agents, and warfarin), and the risks of stroke and ICH were analyzed. The risks of ischemic stroke and ICH were further compared between patients treated with warfarin and nonvitamin K antagonist OACs (NOACs) from 2012 to 2015 when NOACs were available in Taiwan. RESULTS: Compared with patients without AF, patients with AF had an increased risk of ischemic stroke (event number/patient number, incidence = 742/11 064, 5.75%/y versus 1399/14 658, 3.00%/y; hazard ratio, 1.93; 95% confidence interval, 1.74-2.14) and similar risk of ICH (131/11 064, 0.97%/y versus 206/14 658, 0.54%/y; hazard ratio, 0.85; 95% confidence interval, 0.66-1.09) in competing risk analysis for mortality. Among patients with AF, warfarin use was associated with a lower stroke risk (39/617, 3.83%/y versus 742/11 064, 5.75%/y; hazard ratio, 0.69; 95% confidence interval, 0.49-0.96 in a competing risk model), with no difference in ICH risk compared with nontreatment. When compared with no antithrombotic therapy or antiplatelet drugs, warfarin was associated with a positive net clinical benefit. These findings persisted in propensitymatched analyses. Compared with warfarin, NOACs were associated with a lower risk of ICH (4/978, 0.42%/y versus 19/768, 1.63%/y; hazard ratio, 0.32; 95% confidence interval, 0.10-0.97 in a competing risk model), with no difference in risk of ischemic stroke. CONCLUSIONS: Among patients with AF ≥90 years of age, warfarin was associated with a lower risk of ischemic stroke and positive net clinical benefit. Compared with warfarin, NOACs were associated with a lower risk of ICH. Thus, OACs may still be considered as thromboprophylaxis for elderly patients, with NOACs being the more favorable choice.