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Oral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence

Published:March 24, 2017DOI:https://doi.org/10.1016/j.ejim.2017.03.012

      Highlights

      • Half of octogenarians with AF receive recommended OAT mainly due to safety concerns.
      • VKAs have been the gold standard of OAT for decades, but have many disadvantages.
      • DOACs prevent strokes at least as well as VKAs, with less intracranial hemorrhages.
      • DOACs may allow a greater number of older AF patients to receive recommended OAT.
      • Methods for global evaluation of older AF patients and tailored OAT are discussed.

      Abstract

      Atrial fibrillation is more frequent in older patients, who have a higher risk of cardioembolic stroke and thromboembolism. Oral anticoagulant therapy is the standard of treatment for stroke prevention; however, under-prescription is still very common in older patients. The reasons underlying this phenomenon have not been systematically investigated, and true contraindications only partially account for it. An intimate skepticism on the real benefit-risk balance of oral anticoagulant therapy in the oldest patients seems to derive from the fact that most studies supporting it were conducted decades ago and included younger patients, with overall better functional and clinical status.
      In this review we will focus on the main barriers to anticoagulant therapy prescription in older patients and summarize the available evidences on the efficacy and safety of vitamin K antagonists and direct oral anticoagulants in this population. The encouraging evidence of a higher net clinical benefit of direct oral anticoagulants compared with warfarin should hopefully widen the treatment options also for frail individuals, thereby allowing a greater number of patients to be treated according to current international guidelines.

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