Warfarin In Elderly Patients Research Articles

Efficacy and safety of direct oral anticoagulants versus warfarin in elderly patients with cancer-associated venous thromboembolism

Background Little is known about the effects of direct oral anticoagulants (DOACs) in cancer[1]related venous thromboembolism patients. Methods Data of patients with cancer-related venous thromboembolism (VTE) were retrieved from King Abdulaziz Medical City Database during 2016–2020. We excluded patients who were not using oral anticoagulants, used anticoagulants for <30 days, used 2 agents concomitantly or switched anticoagulants,were aged <65. The primary outcomes were recurrent VTE,major bleeding, and death from any cause. Results We identified 717 patients who received a diagnosis of cancer-related VTE. After the exclusion criteria were applied, 445 patients remained, 298 were used warfarin, and 147 were received NOACs. Both groups were followed up for 12±2 months. The mean age of the patients was 71 ± 8 in the DOACs group and 76 ±6 in the warfarin group (p > 0.05); 48.24% of patients in the DOAC group and 46.98% of patients in the warfaringroup were men (p > 0.05). The mean HAS-BLED score was 3.7 ± 3.8 in the NOAC group and 3.8 ± 3.9 in the warfaringroup (p > 0.05). Furthermore, among patients with cancer-related VTE, DOAC was associated with no difference in major bleeding or recurrence events (CRR = 0.91, 95% CI = 0.78–1.05; CRR = 0.63, 95% CI = 0.52–0.77, respectively), and significantly reduced death from any cause (aHR = 0.65, 95% CI = 0.52–0.80) compared with warfarin. Conclusions In elderly patients with cancer-related VTE, DOAC was associated with reduced death from any cause compared with warfarin, whereas no difference in major bleeding or recurrent VTE were observed between these treatment modalities.

The Oral Anticoagulants Administration in Elderly Patients with Geriatric Syndromes: What's New?

The administration of oral anticoagulants in elderly patients with geriatric syndromes such as senile asthenia syndrome, falls and high risk of falls, dementia, polymorbidity, polypharmacy are discussed in the article. The evidence base for the anticoagulants taking in patients with atrial fibrillation aged ≥75, ≥80, ≥85 and ≥90 years, in patients with atrial fibrillation and various geriatric syndromes, as well as in elderly patients with venous thromboembolic complications and frailty syndrome is presented. Most studies indicate significant advantages of direct oral anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban) over the vitamin K antagonist warfarin in elderly patients with geriatric syndromes. An updated version of the FORTA consensus document, which aims to optimize the prescription of medicines for the elderly, is also presented. Apixaban has a FORTA-A safety class and is the safest oral anticoagulant in elderly patients.

Non-vitamin K antagonist oral anticoagulants have better efficacy and equivalent safety compared to warfarin in elderly patients with atrial fibrillation: A systematic review and meta-analysis

BackgroundTo evaluate the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in elderly patients (aged ≥75 years) with atrial fibrillation (AF), depending on dose and/or renal function. MethodsAfter systematically searching the databases (Medline, EMBASE, CENTRAL, SCOPUS, and Web of Science), 5 phase III randomized controlled trials and reported data according to subgroups of elderly/non-elderly AF patients, comparing any NOACs and warfarin were included. The primary efficacy and safety outcomes were stroke/systemic thromboembolism and major bleeding. Results(1) NOACs showed better efficacy than warfarin in elderly patients [RR 0.83 (0.69–1.00), p=0.04, I2=55%], but equivalent efficacy in non-elderly patients. (2) NOACs reduced major bleeding compared to warfarin in non-elderly (p<0.001) and had comparable safety to warfarin in elderly patients. (3) Even in elderly patients with moderately impaired renal function, NOACs had a safety profile comparable to that of warfarin for major bleeding if dose reduction was reached appropriately [pooled RR 0.82 (0.35–1.88), p=0.63, I2=63%]. (4) All-cause mortality was lower with NOACs in non-elderly patients [RR 0.89 (0.83–0.95), p=0.001, I2=0%], and with standard-dose NOAC group of elderly patients [RR 0.93 (0.86–1.00), p=0.04, I2=0%] compared to warfarin. ConclusionsFor elderly patients (aged ≥75 years), NOACs showed better efficacy and equivalent safety compared to warfarin even in those with moderately impaired renal function. All-cause mortality was lower with standard-dose NOACs compared to warfarin in the elderly patient group. Systematic review registrationThe protocol of this meta-analysis was registered on PROSPERO under CRD42016047922 (https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016047922).

Anticoagulation therapy in the elderly with non-valvular atrial fibrillation: a double-edged sword

Prevalence of non-valvular atrial fibrillation is increasing over time. Particularly in elderly population, treatment strategies to reduce the rate of stroke are challenging and still represent an unsolved cultural question. Indeed, the risk of thromboembolism increases in the elderly in parallel with the risk of bleeding. The frequent coexistence of several morbidities, frailty syndrome, polypharmacy, chronic kidney disease and dementia strengthens the perception that risk-benefit ratio of anticoagulant therapy could be unfavorable, and explains why such treatment is underused in the elderly. Recently, the introduction of non-vitamin K oral anticoagulants (NOACs) has allowed us to overcome the large number of limitations imposed by the use of vitamin K antagonists. In this manuscript, the benefits of individual NOACs in comparison with warfarin in elderly patients are reviewed. Targeted studies on complex elderly patients are needed to test usefulness of a geriatric comprehensive assessment, besides the scores addressing risk of thromboembolic and hemorrhagic events. In the meantime, it is mandatory that use of anticoagulant therapy in most elderly people, currently excluded from randomized controlled trials, is prudent and responsible.

Stroke prevention using dabigatran in elderly Chinese patients with atrial fibrillation

Little is known about the clinical benefit of a non-vitamin K antagonist oral anticoagulant compared with warfarin in elderly Chinese patients with atrial fibrillation (AF). The purpose of this study was to evaluate the clinical benefit of dabigatran in elderly (age ≥80 years) Chinese patients with nonvalvular AF with regard to the risk of ischemic stroke and intracranial hemorrhage (ICH). This was an observational study. We studied 571 Chinese patients (mean age 84.8 ± 4.0 years; 58.1% women) with nonvalvular AF. The primary outcome was hospital admission for ischemic stroke, and the secondary outcome was admission for ICH. The mean CHA2DS2-VASc (congestive heart failure [1 point], hypertension [1 point], age 65-74 years [1 point] and age ≥75 years [2 points], diabetes mellitus [1 point], prior stroke or transient ischemic attack [2 points], vascular disease [1 point], sex category [female] [1 point]) and HAS-BLED (hypertension [1 point], abnormal renal/liver function [1 point], stroke [1 point], bleeding history [1 point] or predisposition [1 point], labile international normalized ratio [1 point], elderly [age >65 years] [1 point], drugs/alcohol concomitantly [1 point]) scores were 4.8 ± 1.6 and 2.4 ± 0.8, respectively. Of 571 patients, 129 (22.6%) were taking dabigatran 110 mg twice daily and the remaining were on warfarin. After a mean follow-up of 2.6 years (a total of 1471 patient-years), ischemic stroke occurred in 83 patients on warfarin (6.9% per year) compared with 4 patients on dabigatran (1.4% per year) (hazard ratio 0.22; 95% confidence interval 0.23-0.67). There were 8 incidences of ICH: 7 in patients on warfarin (0.59% per year) and 1 patient on dabigatran (0.35% per year). Dabigatran was associated with a substantially lower ischemic stroke risk (1.4% per year vs 5.4% per year) and similar ICH risk (0.35% per year vs 0.36% per year) as compared with warfarin with time in therapeutic range (TTR) ≥55%. In elderly Chinese patients with AF, this study suggested that dabigatran achieved superior stroke risk reduction and similar risk of ICH compared with warfarin with TTR ≥55%. Dabigatran may be preferable to warfarin in elderly patients with AF for stroke prevention, particularly in those with poor TTR.

Use of Warfarin in Elderly Patients With Non-Valvular Atrial Fibrillation – Subanalysis of the J-RHYTHM Registry –

To clarify the effects of warfarin therapy in very old patients with non-valvular atrial fibrillation (NVAF), a post-hoc analysis was performed using the data of the J-RHYTHM Registry. A consecutive series of AF outpatients was enrolled from 158 institutions. Of 7,937 patients, 7,406 with NVAF (men, 70.8%; 69.8±10.0 years) were followed for 2 years or until an event occurred. Patients were divided into 3 age groups (<70, 70-84, and ≥85 years) and 5 subgroups according to international normalized ratio (INR; <1.6, 1.6-1.99, 2.0-2.59, 2.6-2.99, and ≥3.0). Prevalence of female sex, permanent AF, hypertension, coronary artery disease, heart failure, and history of ischemic stroke/transient ischemic attack was higher in the older groups. In the oldest group, 79.7% of patients received warfarin and their time in therapeutic range, using the Japanese target INR of 1.6-2.6, was 67.1%. Rate of thromboembolic events was lower in the age groups <70 and 70-84 years (P=0.027 and P<0.001, respectively) for patients receiving warfarin compared with those who were not. In the oldest group, the rate of thromboembolism plus major hemorrhage was lower at INR 1.6-2.59. Warfarin could have beneficial effects even in very old NVAF patients if INR is kept between 1.6 and 2.59.

Venous thromboembolism in the elderly: efficacy and safety of non-VKA oral anticoagulants

Increasing age and renal impairment are risk factors for venous thrombosis but also for anticoagulant-induced bleeding. In large-scale phase III trials, non-VKA oral anticoagulants (NOACs) were at least as effective and safe for the treatment of acute venous thromboembolism as warfarin. Here, we review the efficacy and safety of dabigatran, rivaroxaban, apixaban and edoxaban in the subgroups of elderly patients (≥75 years) and patients with impaired renal function (creatinine clearance ≤50 ml/min). In all phase III trials, the efficacy of NOACs in the prevention of recurrent VTE was conserved both in the elderly subgroup and in the subgroup with impaired renal function. In a meta-analysis of the pooled results, NOACs reduced VTE recurrence compared with warfarin in elderly patients. In elderly patients and patients with impaired renal function, the safety of NOACs was in line with the results of the overall study.NOACs may offer an effective, safer and more convenient alternative for VKAs also in the elderly. However, the efficacy/safety profile of NOACs in the aged population needs to be confirmed in real-life.

Psychological effects of treatment with new oral anticoagulants in elderly patients with atrial fibrillation: a preliminary report.

Background and aimsAtrial fibrillation (AF) is the most common arrhythmia in elderly people, yet oral anticoagulation is underused in the aged. We tried to determine whether new oral anticoagulants (NOA) have greater psychological tolerability than warfarin.MethodsAge-, gender-matched groups of AF patients receiving NOA (N = 15) or warfarin (N = 15) were assessed with the Anti-Clot Treatment Scale (ACTS) and the Perceived Stress Scale (PSS).ResultsPatients were old (81 ± 9 years). NOA group showed greater psychological satisfaction, with lower therapy-related burden (ACTS burdens: 16.3 ± 4.5 vs. 32.9 ± 10.2, p < 0.001) and higher awareness of benefits (ACTS benefits: 13.0 ± 1.3 vs. 10.8 ± 1.9, p = 0.001). Even stress was lower (PSS: 13.1 ± 4.0 vs. 17.1 ± 4.2, p = 0.013). The multivariate analysis confirmed these findings, showing that higher levels of anxiety and depression could justify more stress in warfarin patients.ConclusionsThe results of this preliminary study show that NOA have an improved psychological impact compared with warfarin in elderly patients.

Underutilization of Warfarin Therapy in Elderly Patients with Atrial Fibrillation - Fear or False Sense of Security!

Background: Under utilization of warfarin in elderly patients with atrial fibrillation (AF) has been recognized as a significant health care issue. This study examines the rate and reasons for warfarin underutilization in elderly patients with AF at the Kansas City Veterans Affairs Medical Center. Methods: Retrospective study reviewing electronic medical records of all patients aged 65 and older with the diagnosis of atrial fibrillation. Patients on warfarin were excluded. Reasons for not using warfarin were extracted by reviewing the electronic medical record. Anticoagulation indications for these patients were determined based on the ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation. Results: Warfarin was not used by 407 patients (25%) with known AF. Average age was 79+6.2 years. 60% of patients had persistent or permanent AF. Prevalence of risk factors for thromboembolism included hypertension (74%), heart failure or ejection fraction of <40% (21%), diabetes (27%) and coronary artery disease (48%). CHADS (2) scores were documented in the charts less than 1% of the times. Only 11 patients had CHADS (2) score of 0 and 70 had a score of 1. A class I or IIa indication for warfarin therapy was present in 298 (73%) of patients. Return to sinus rhythm (37%) was the most common reason for not using warfarin. In 30% of cases the reason not to use warfarin was not addressed. Other reasons not to use warfarin included fear of falls (7%), prior head or GI bleed (14%), patient refusal & noncompliance (12%). History of CVA or TIA was documented in 12% of patients. Conclusions: Underutilization of warfarin in elderly patients with atrial fibrillation remains a common problem despite their high risk for thromboembolic events. A false sense of security about the paroxysmal nature of AF, lack of proper insight about stroke risk (CHADS (2)), and fear of bleeding are the most common reasons for non use of warfarin.

Stroke prevention in atrial fibrillation – things can only get better

Stroke prevention in atrial fibrillation – things can only get better

Bleeding Complications in Elderly Patients Following Acute Myocardial Infarction

The article by Buresly and colleagues1 adds valuable information about the safety of combining aspirin with thienopyridine derivatives and/or warfarin in elderly patients receiving routine clinical care. Three points are relevant and complementary to the data presented in their study.

Bleeding Complications Associated With Combinations of Aspirin, Thienopyridine Derivatives, and Warfarin in Elderly Patients Following Acute Myocardial Infarction

Bleeding Complications Associated With Combinations of Aspirin, Thienopyridine Derivatives, and Warfarin in Elderly Patients Following Acute Myocardial Infarction

Bleeding Complications Associated With Combinations of Aspirin, Thienopyridine Derivatives, and Warfarin in Elderly Patients, Following Acute Myocardial Infarction

Background: Combinations of aspirin with thienopyridinederivatives(clopidogrelbisulfateorticlopidinehydrochloride) and/or warfarin sodium are increasingly being used in various cardiac conditions. However, little is known about the bleeding risks associated with these combinations, particularly in elderly individuals at the population level. This study estimates the bleeding risks associated with combinations of aspirin, thienopyridine derivatives, and warfarin in elderly patients. Methods: We conducted a population-based observational cohort study using linked administrative databases. A total of 21443 elderly survivors of acute myocardial infarctionbetween1996and2000werestudied.Patientswere divided into 5 groups according to drug exposure: aspirin alone,warfarinalone,aspirinplusathienopyridinederivative (antiplatelet combination), aspirin plus warfarin (anticoagulant combination), and aspirin plus warfarin plus a thienopyridine derivative (3-drug combination). Hospitalizations for bleeding events were examined. Results:Hospitalizations for bleeding were observed in 1428 patients (7%). Compared with rates of patients receivingaspirinalone(0.03perpatient-year),ratesofbleeding were higher among patients receiving the antiplateletcombination(0.07perpatient-year),theanticoagulant combination(0.08perpatient-year),andthe3-drugcombination (0.09 per patient-year). Compared with aspirin alone, the adjusted odds ratios (95% confidence intervals) for bleeding were 1.65 (1.02-2.73) for patients receiving the antiplatelet combination and 1.92 (1.282.87) for patients receiving the anticoagulant combination. Only 1 of 141 patients in the 3-drug combination group had a bleeding event.

Prognostic Implications of Warfarin Cessation After Major Trauma

Warfarin therapy is often withheld from elderly patients who fall or otherwise experience injury because of concerns regarding the long-term risk of hemorrhage in these individuals. We studied whether stopping warfarin after trauma is associated with a higher risk of subsequent adverse cardiovascular events. We conducted a retrospective, population-based, cohort study using linked administrative databases in the province of Ontario, Canada for the years 1992 to 2001. A total of 8450 elderly patients (age >65 years) who survived an incident of major trauma and were receiving warfarin before injury were followed up for a mean of 3.3 years. During the 6-month interval after trauma, 1827 (22%) patients discontinued warfarin, whereas 6623 (78%) patients continued warfarin. Warfarin cessation was not associated with an increased risk of subsequent stroke (hazard ratio [HR] 0.99, 95% CI 0.82 to 1.21) or myocardial infarction (HR 0.94, 95% CI 0.74 to 1.20) but was associated with a lower risk of major hemorrhage (HR 0.69, 95% CI 0.54 to 0.88) and a higher risk of venous thromboembolism (HR 1.59, 95% CI 1.07 to 2.36). Adjustment for baseline demographics, stroke risk factors, other comorbidities, and characteristics of the trauma did not materially change these findings. On-treatment analyses yielded similar results. Cessation of warfarin in elderly patients after major trauma was not associated with an increased risk of arterial thrombotic events but was associated with a significantly increased risk of venous thromboembolism.

Bleeding Complications Associated With Combinations of Aspirin, Thienopyridine Derivatives, and Warfarin in Elderly Patients Following Acute Myocardial Infarction

Combinations of aspirin with thienopyridine derivatives (clopidogrel bisulfate or ticlopidine hydrochloride) and/or warfarin sodium are increasingly being used in various cardiac conditions. However, little is known about the bleeding risks associated with these combinations, particularly in elderly individuals at the population level. This study estimates the bleeding risks associated with combinations of aspirin, thienopyridine derivatives, and warfarin in elderly patients. We conducted a population-based observational cohort study using linked administrative databases. A total of 21,443 elderly survivors of acute myocardial infarction between 1996 and 2000 were studied. Patients were divided into 5 groups according to drug exposure: aspirin alone, warfarin alone, aspirin plus a thienopyridine derivative (antiplatelet combination), aspirin plus warfarin (anticoagulant combination), and aspirin plus warfarin plus a thienopyridine derivative (3-drug combination). Hospitalizations for bleeding events were examined. Hospitalizations for bleeding were observed in 1428 patients (7%). Compared with rates of patients receiving aspirin alone (0.03 per patient-year), rates of bleeding were higher among patients receiving the antiplatelet combination (0.07 per patient-year), the anticoagulant combination (0.08 per patient-year), and the 3-drug combination (0.09 per patient-year). Compared with aspirin alone, the adjusted odds ratios (95% confidence intervals) for bleeding were 1.65 (1.02-2.73) for patients receiving the antiplatelet combination and 1.92 (1.28-2.87) for patients receiving the anticoagulant combination. Only 1 of 141 patients in the 3-drug combination group had a bleeding event. In practice, antiplatelet and anticoagulant combinations lead to modest increases in bleeding risk in elderly patients, but the overall risk is small.

825-1 Efficacy and safety of ximelagatran compared with well-controlled warfarin in elderly patients with nonvalvular atrial fibrillation: Observations from the SPORTIF trials

825-1 Efficacy and safety of ximelagatran compared with well-controlled warfarin in elderly patients with nonvalvular atrial fibrillation: Observations from the SPORTIF trials

Early prediction of the sensitivity of warfarin in elderly patients by the fall in factor VIIc and protein C at the induction of treatment

Indications of oral anticoagulation (OA) therapy for venous thromboembolism and atrial fibrillation increase with age [1]. Elderly patients are more sensitive to OA [2] and their risk for bleeding complications is increased [3,4]. There is a strong relationship between the intensity of the anticoagulant effect and the risk of bleeding [5,6]. A recommendation for an international normalized ratio (INR) of 2.0 to 3.0 is made for most indications [1]. It is important to maintain INR below 3.0 especially in the elderly [7]. Many authors agree that there is a need to improve the safety of anticoagulants in the elderly by careful monitoring of anticoagulant therapy in order to maximize their time in the optimal therapeutic range [1,2,8]. The start of this treatment is a critical period, as the hemorrhagic risk lies mainly in the induction phase [4]. Warfarin is the most widely used oral anticoagulant. It is a drug with a small therapeutic window and its dose–response curve is complex [9,10]. There is a great interand intraindividual pharmacokinetic and pharmacodynamic variability [11]. For all these reasons, it is difficult to predict the correct induction dose [12]. INR is the

Warfarin in elderly patients with NVAF: more data needed

Warfarin in elderly patients with NVAF: more data needed

DEATHS ASSOCIATED WITH WARFARIN IN ELDERLY PATIENTS

SUMMARY The four cases presented illustrate fatal errors in the management of elderly patients at different stages in the chain of their anticoagulation treatment. As indications for anticoagulation increase in the elderly, more care needs to be taken.