Anticoagulation Therapy In Elderly Patients Research Articles

How to Improve Very Low Adherence to Anticoagulation Therapy in Elderly Patients with Non-Valvular Atrial Fibrillation [Letter

How to Improve Very Low Adherence to Anticoagulation Therapy in Elderly Patients with Non-Valvular Atrial Fibrillation [Letter

Non‑persistence to Oral Anticoagulation Therapy in Elderly Patients with Non‑valvular Atrial Fibrillation

Non‑persistence to Oral Anticoagulation Therapy in Elderly Patients with Non‑valvular Atrial Fibrillation

Current Use of Oral Anticoagulation Therapy in Elderly Patients with Atrial Fibrillation: Results from an Italian Multicenter Prospective Study-The ISNEP Study.

Background: Atrial fibrillation (AF) is the most common heart arrhythmia, and its prevalence increases with age. Oral Anticoagulant Therapy (OAT) with non-vitamin K antagonist oral anticoagulants (NOACs) or vitamin K antagonists (VKAs) is essential to avoid thromboembolic events in AF. However, this treatment is associated with a high risk of bleeding and low adherence in elderly patients. Aim: The aim was to evaluate the real-world use of OAT in a population of patients aged ≥80 years in twenty-three Italian centers and to investigate the tolerance of and patient satisfaction with this therapy. Methods: The ISNEP Study is a multicenter cross-sectional study enrolling patients with AF and aged ≥80 years and treated with either NOACs or VKAs. A written questionnaire was administered to each patient to evaluate the adherence to and patient satisfaction with this therapy. Results: The study included 641 patients with a mean age of 85 (82–87) years. The use of NOACs was reported in 93.0% of cases, with the remaining 7.0% treated with VKAs. A history of stroke events was reported in five (11.1%) and one (0.2%) patients in the VKA and NOAC groups, respectively. The rate of referred ecchymosis/epistaxis was significantly higher in the VKA group compared to the NOAC group (p < 0.001). Patients receiving NOACs reported a substantial improvement in their quality of life compared to the VKA group. Conclusions: A small, but not negligible, proportion of elderly AF patients is still treated with VKAs. Patients treated with NOAC have a higher level of satisfaction with the therapy and complete adherence.

Oral anticoagulation therapy in elderly patients with atrial fibrillation

Oral anticoagulation therapy in elderly patients with atrial fibrillation

Adherence to Anti-coagulant therapy in elderly patients with Atrial fibrillation in the Kyrgyzstan

Introduction: Anticoagulant therapy can prevent adverse outcomes of Atrial fibrillation (AF), reducing the risk of stroke by 64% and death by 25%. The present study aimed to assess treatment adherence in elderly patients with non-valvular atrial fibrillation (NVAF) who were prescribed the vitamin K antagonist warfarin.&#x0D; &#x0D; Materials and methods: In the present retrospective study, we analyzed the medical records of 202 elderly outpatients with NVAF aged between 65 and 74 years (mean ± SD: 68.7 ± 10.2 years). &#x0D; &#x0D; Results: Problems associated with warfarin arose throughout the follow-up period. After 1 month of treatment, the number of patients taking warfarin had decreased to 71.3% of all patients; less than half of the patients (46%) were still taking the drug. In subsequent periods, the number continued to decrease; of all patients who had been prescribed warfarin with periodic international normalized ratio (INR) control, only 19 (9.4%) remained after 1 year. Our study revealed inadequate anticoagulation therapy in elderly patients, probably because most patients refused warfarin therapy because they could not control their INR. Moreover, significantly more rural residents than urban residents refused therapy (48 vs. 22; p &lt; 0.05). Doctors underprescribed anticoagulants because they feared hemorrhagic complications in their patients.&#x0D; &#x0D; Conclusion: The results of the present study showed that anticoagulants were underprescribed at the outpatient stage in centers of family medicine in our country. The main drug of choice for specialists remains warfarin, which only provides adequate therapy in a small number of patients (9.4%).

Frailty Status Affects the Decision for Long-Term Anticoagulation Therapy in Elderly Patients with Atrial Fibrillation.

Elderly patients are underrepresented in the studies concerning anticoagulation therapy (AT) in atrial fibrillation (AF), while patients' frailty status is lacking in most of the studies. Our objective was to evaluate AT in AF elderly patients and study the effect of patients' frailty status on their long-term AT. We conducted an observational prospective study that enrolled consecutive AF patients (≥75years) who were hospitalized in the Department of Internal Medicine of the University Hospital of Heraklion, Crete, Greece from 1 June 2015 to 1 June 2016. We recorded the AT on admission and at discharge, all-cause mortality, and hospital readmission in a follow-up period of 1year after hospital discharge. Frailty status was assessed by pre-established scores. One hundred and four consecutive patients (49% male; median age 87years) were enrolled, 78 (78.8%) of whom received AT at discharge. Patients who did not receive AT at discharge had a higher HEMORR2HAGES (Hepatic or renal disease, Ethanol abuse, Malignancy, Older age, Reduced platelet count or function, Re-bleeding, Hypertension, Anemia, Genetic factors, Excessive fall risk and Stroke) score (5.5 ± 1.15 vs. 4.79 ± 1.68; p = 0.032), a lower Katz score (2.48 ± 2.23 vs. 4.08 ± 2.25; p = 0.006), and a higher Clinical Frailty Scale score (7 ± 1.95 vs. 5.57 ± 2.05; p = 0.006). Sixty-five patients (62.5%) were readmitted to a hospital during the follow-up period. In-hospital death occurred in five patients (4.8%) and 57 patients (57.6%) died within the follow-up period. A high percentage of the elderly AF patients did not receive AT, even at discharge. Patients who did not receive AT at discharge had higher bleeding and frailty scores. In the 1-year follow-up period after hospital discharge, high all-cause mortality and a high number of hospital readmissions were recorded.

Direct oral anticoagulants use in elderly patients with non valvular atrial fibrillation: state of evidence.

Non-valvular atrial fibrillation (NVAF) increases the risk of stroke by three- to five-fold, especially in elderly patients, creating a huge burden on medical system as well as a negative impact on patients' lives. Balancing efficacy and bleeding risk is a challenge when considering anticoagulation therapy in elderly patients, because of their frequent high risk of both stroke and bleeding. Real world data reveal the underuse of anticoagulation in the elderly, especially due to physicians' fear of bleeding, often neglecting the thromboembolic risk. Care of elderly patients with NVAF is often complicated by factors including adherence, cognitive impairment, health literacy, risk of falling, adverse effects, involvement of caregivers, and patient-physician relationship. Therefore, shared decision making and conversations between clinicians and patients are crucial. In addition, elderly patients often suffer from multiple comorbidities, requiring multiple concomitant medications, with an increased risk of drug interactions. Four non-vitamin K antagonist oral anticoagulants, the so-called direct oral anticoagulants (DOACs) - dabigatran, rivaroxaban, apixaban and edoxaban - have been approved for reducing the risk of stroke and systemic embolism in patients with NVAF. Clinical trials and real-world data show the advantages of this class of drugs compared to conventional anticoagulation in the treatment of elderly patients with NVAF and identify subgroups of older patients who may be more suitable candidates for particular agents. However, there are conflicting opinions on the absolute benefit of DOACs use in elderly patients. A key factor to consider is that elderly patients frequently suffer from renal impairment and therefore dose adjustments according to creatinine clearance are mandatory for DOACs. As each DOAC comes with its own unique advantages and safety profile, a personalized case by case approach should be adopted to decide on the appropriate anticoagulation regimen for elderly patients after weighing the overall risks and benefits of therapy.

073_16970-F1 Is the Long-Term Anticoagulation Management of Atrial Fibrillation Beneficial in Non-Selected Frail Elderly Patients?

Age appropriateness of long-term anticoagulation in atrial fibrillation (AF) is still uncertain. We aimed to evaluate the AF anticoagulation therapy in elderly patients. Single-center, observational study which included consecutive elderly patients (>70 years) with known AF, hospitalized at the

Anticoagulation therapy in elderly patients with atrial fibrillation: results from the Registry of Atrial Fibrillation To Investigate the Implementation of New Guidelines (RAFTING).

Patients with atrial fibrillation aged 75 years or older have a CHA2DS2VASc 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. Atrial Fibrillation To Investigate the Implementation of New Guidelines , a countrywide prospective registry performed in Greece during 2010, a period when only vitamin-K antagonists (VKA) were available, enrolled 1127 patients with atrial fibrillation diagnosis during Emergency Departments visit in 31 representative hospitals; 807 patients had known atrial fibrillation and of those, 342 aged 75 years or older. We recorded preadmission anticoagulation treatment and associated it with clinical characteristics and stroke/bleeding risk. Patients on VKA (n = 207; 61%) were younger (81 ± 4 vs. 83 ± 5; P < 0.001) but no other significant differences were noticed, including mean CHA2DS2VASc (high: 2-4, very high: >4) or modified HASBLED (low: 0-2, high: >2) scores. VKA were prescribed in 65% of patients with very high CHA2DS2VASc score as compared with 55% of those with high score (P = 0.065). VKA were used equally in low or high-modified HASBLED score (61% vs. 59%; P = 0.78). The interaction between CHA2DS2VASc and HASBLED was significant (P < 0.001) in patients on VKA; in patients with low HASBLED, VKA use was similar in high versus very high CHA2DS2VASc score (58 vs. 64%), whereas in patients with high HASBLED, VKA use tended to be higher in very high versus high CHA2DS2VASc score (66 vs. 43%). In this countrywide atrial fibrillation registry, 61% of elderly patients received VKA, a decision driven mainly by stroke risk. VKA use was not higher in patients with low bleeding risk.

A survey on anti-thrombosis treatment plans for elderly patients with non-valvular atrial fibrillation in the different divisions of internal medicine

Objective To identify anti-thrombosis treatment plans for hospitalized elderly patients with non-valvular atrial fibrillation adopted by the different divisions of the internal medicine department. Methods Retrospective data on CHADS2 scores and the frequencies of anti-platelet aggregation and anticoagulation medication in 990 elderly hospitalized patients with non-valvular atrial fibrillation in the different divisions of internal medicine were analyzed. Results Most of the 990 subjects were located in Cardiology (357 cases, 36.1%), Geriatrics (131 cases, 13.2%), the Cadres' Ward (162 cases, 16.4%) and Neurology (138 cases, 13.9%), while a minority stayed in Emergency Medicine (70 cases, 7.0%), Respiratory Medicine (56 cases, 5.7%), Endocrinology (38 cases, 3.8%), Gastroenterology (20 cases, 2.0%) and Nephrology (18 cases, 1.8%). Of the 573 cases with a CHADS2 score of 2 or higher, 58.1% (333/573) received single antiplatelet aggregation therapy, 24.1% (138/573) received dual antiplatelet aggregation therapy and only 14% (80/573) received anticoagulation therapy (warfarin + new oral anticoagulants). The proportion of patients receiving anticoagulation (warfarin) was relatively high in Cardiology (20.1%, 43/214), Geriatrics (17.2%, 10/58) and the Cadres' Ward (13.1%, 11/84). Conclusions The use of anticoagulation therapy in elderly patients with non-valvular atrial fibrillation is generally infrequent and is relatively more commonly used in Cardiology, Geriatrics, and the Cadres' Ward than in other divisions of internal medicine. Key words: Atrial fibrillation; Platelet aggregation inhibitors

Study on the quality and prognosis of long-term oral anticoagulation therapy in elderly patients with non-valvular atrial fibrillation

Objective To investigate the status of oral anticoagulation therapy (OAC) in elderly patients with non-valvular atrial fibrillation, and evaluate its quality and the curative efficacy. Methods The research was a single center registration study in a tertiary referral hospital in Beijing. We registered 564 consecutive patients with non-valvular atrial fibrillation including 348 elderly patients (61.7%) who were over 65-years old from Aug 2012 to Dec 2013. The anticoagulation status of patients, clinical events and quality of anticoagulation treatment were documented by a long-term follow-up of all patients. Quality of anticoagulation was expressed as time in therapeutic range (TTR) calculated by the linear interpolation method. Results A total of 309 patients consisted of the cohort of study after excluding patients undergoing catheter ablation. The mean follow-up time was (13.4±4.8) months. 92 patients (30.2%) were in long-term adherence to oral anticoagulant therapy including 55 cases (35.3%) in group aged 65-74 years and 37 cases (25.0%) in group aged 75-92 years. A total of 599 INR values from 67 patients (72.8%) were acquired for analysis. The mean INR was 2.1. The overall mean TTR was 56.2%. There was no significant difference in the analysis of TTR between the two groups at different ages. All-cause mortality was higher in group aged 75-92 years than in group aged 65-74 years 〔8.8% (13 cases) vs. 2.6% (4 cases), P<0.05〕. But no difference in mortality associating thrombotic and hemorrhagic events caused by atrial fibrillation and OAC was observed between the two age groups. The annual stroke incidence was 3.1% (11 cases) in total population, and there was no difference in the annual stroke incidence between the two age groups. The rate of hemorrhage which mainly was minor bleeding, was higher in warfarin group than in the non-warfarin group 〔31.2% (34 cases) vs. 11.8% (23 cases), P<0.01〕. There was no significant difference in minor or intracranial hemorrhagic events between the two age groups. Conclusions The elderly patients with non-valvular atrial fibrillation in China are inadequately treated with anticoagulation. High quality of anticoagulation significantly reduces thromboembolic events in the elderly patients, even in those above 75 years old, without increasing major bleeding events. Key words: Atrial fibrillation; Warfarin; Follow-up studies

Warfarin doses for anticoagulation therapy in elderly patients with chronic atrial fibrillation

OBJECTIVE:Anticoagulation is a challenge for the prophylaxis of thromboembolic events in elderly patients with chronic atrial fibrillation. Stable anticoagulation is defined as the time within >70% of the therapeutic range. However, the dosage required to achieve stable anticoagulation remains unknown. The aim of this study was to analyze the warfarin dose necessary for the maintenance of stable oral anticoagulation therapy in elderly patients.METHODS:We analyzed 112 consecutive outpatients with atrial fibrillation who were ≥65 years of age, had received anticoagulation therapy with warfarin for more than 1 year and had a stable international normalized ratio between 2.0 and 3.0 for ≥6 months. The international normalized ratio was measured in the central laboratory using the traditional method.RESULTS:The patients were stratified according to the following age groups: <75 or ≥75 years and <80 or ≥80 years. The mean daily doses of warfarin were similar for patients <75 or ≥75 years (3.34±1.71 versus 3.26±1.27 mg/day, p = 0.794) and <80 or ≥80 years (3.36±1.49 versus 3.15±1.23 mg/day, p = 0.433). In 88 (79%) patients, the daily warfarin dose was between 2 and 5 mg/day; in 13 (11%) patients, the daily warfarin dose was <2.0 mg/day; and in 11 (10%) patients, the daily warfarin dose was >5.0 mg/day. The correlation between the daily warfarin dose and the international normalized ratio was 0.22 (p = 0.012).CONCLUSION:Stable anticoagulation was achieved in 80% of patients who received doses of 2 to 5 mg/day of warfarin, and the mean daily dose was similar across the age groups analyzed.

Percutaneous closure of left atrial appendage after transcatheter aortic valve implantation - an interventional approach to avoid anticoagulation therapy in elderly patients: TAVI and closure of LAA to avoid warfarin therapy

Percutaneous closure of left atrial appendage after transcatheter aortic valve implantation - an interventional approach to avoid anticoagulation therapy in elderly patients: TAVI and closure of LAA to avoid warfarin therapy

Stroke in the Very Elderly

To the Editor: Atrial fibrillation (AF) is the most common, potent, and independent risk factor for ischemic stroke,1 the incidence of which increases with age.2 To determine the influence of advanced age on anticoagulation therapy in elderly patients with AF, a retrospective cohort study of all patients admitted in our department (from 1995 to 2003) was conducted. These patients were >90 years of age and had had an acute stroke. The following parameters were analyzed: age, sex, cardiovascular risk factors and their treatment, and outcome. Among the 404 patients experiencing acute stroke, 39 (9.65%) were >90 years old (average age 91.73±2.34), and 82% were females. Four patients had cognitive impairment (Alzheimer disease) whose quality of life was average for their age. Major risk factors for stroke were AF (64%), hypertension (51%), and diabetes mellitus (7%). Smoking habits, before stroke or transient ischemic attack (TIA), had not …

Incidence of silent postoperative pulmonary emboli in geriatric patients.

Abstract:In an attempt to ascertain the incidence of post‐operative pulmonary emboli (including early small emboli) in the elderly, 50 surgical patients (age range, 21–91) were studied both preoperatively and postoperatively by means of the following: lung scintiscanning (four views), electrocardiograms, chest roentgenograms, and determinations of serum glutamic oxalacetic transaminase (SGOT), lactic dehydrogenase (LDH), and bilirubin. These tests were performed twice postoperatively at one‐week and two‐week intervals.In 4 cases the postoperative lung scan findings were compatible with recent pulmonary emboli, although the patients were asymptomatic. There was no consistent correlation with serum enzyme elevations, nor with the sex of the patient, type of operation, type of anesthesia, or diabetic status. All 4 patients with indications of postoperative emboli were over 40 years of age, and 3 of them had undergone their operations in the lithotomy position. The overall incidence of positive findings with postoperative lung scanning was 8 per cent, but in patients over 40 years of age it was 10 per cent.In view of the significant incidence of postoperative pulmonary emboli and the possible age correlation, further study is needed to ascertain the feasibility of prophylactic postoperative anticoagulation therapy in elderly patients.