Abstract
Growing old is like being increasingly penalized for a crime you haven’t committed. — —Anthony Powell, Temporary Kings Anticoagulation therapy for thromboembolism prophylaxis in patients with atrial fibrillation (AF) is based on quality information derived from numerous randomized controlled trials but continues to be a conundrum for many physicians. The AF treatment guidelines have been revised recently,1 but new information is emerging at such a rapid rate that it is hard to imagine how the guideline process can keep up with the pace. In this issue of the journal, there is new and rather startling information derived from careful observation of the initiation of warfarin therapy in a cohort of elderly patients with AF.2 Several aspects of this study deserve emphasis. Article p 2689 The subjects in the cohort of Hylek et al2 possess some unique characteristics. The obvious one is the age of the patients. All were aged ≥65 years. It is equally notable that none of them had been on warfarin during the preceding year. A substantial proportion of women were included in the cohort. Among those aged ≥80 years, 55% were women. It is also notable that the duration of follow-up was restricted to the first year of warfarin therapy. The most obvious finding to be emphasized is the high proportion of serious bleeding incidents. The reported amount of major bleeding during use of vitamin K antagonists over nearly 2 decades has varied (see Table 42). There is, however, a discernible pattern over time. In general, less major bleeding was reported in older studies than in recent studies. A pooled analysis of the original major randomized controlled trials of anticoagulation for thromboembolism prophylaxis in AF patients reported an annual rate of major hemorrhage of 1.3% in 1994.3 However, it is rare that …
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