BACKGROUND AND AIMS: Anticoagulation therapy in patients with atrial fibrillation (AF) has changed over time, particularly following the introduction of direct oral anticoagulants. However, it is unknown how the uptake of anticoagulation therapy and the related clinical outcomes in elderly patients with AF have changed over time.
METHODS: Patients with new-onset AF were included and divided into three age groups: older adults (65-74 years), elderly (75-84 years), and very elderly (=85 years). Temporal trends in the initiation of oral anticoagulants (OACs), the stroke-free survival, major bleedings including intracerebral haemorrhage (ICH), and all-cause mortality were investigated from 1999 to 2022.
RESULTS: In total, 243 938 patients were included, of whom 89 184 (36.6%) were older adults, 99 002 were elderly (40.6%), and 55 752 (22.8%) were very elderly. The proportion of very elderly patients with AF receiving OACs was 71% in 2022. The absolute improvement in the 5-year probability of stroke-free survival was 10.1% in the older adult patients, 12.8% in the elderly patients, and 3.5% in the very elderly patients. The 5-year absolute risk of ICH increased among the elderly and very elderly AF patients.
CONCLUSIONS: Over the past two decades, the risk of stroke decreased significantly among all age groups, with no subsequent increase in the risk of bleeding among older adults in an era where OACs were almost fully implemented. In the very elderly patients aged =85 years, the risk of stroke only slightly improved over time, with an increase in the risk of ICH.
| Specialty | Score |
|---|---|
| Family Medicine (FM)/General Practice (GP) | |
| General Internal Medicine-Primary Care(US) | |
| Geriatrics | |
| Hemostasis and Thrombosis | |
| Internal Medicine | |
| Cardiology |
Relevant information for clinical practice.
The NOAC RCTs may not have the power to detect an increase in ICH in the very elderly. As the use of these drugs has increased, many of us have had patients with poor outcomes after ICH. The complication also affects providers, as it is iatrogenic and life-altering for patients and families. The study quantifies the ICH risk and may encourage research into alternative management strategies.
This study does not fully address the question of the ris- benefit of DOACs in the very elderly. The findings showed a modest reduction in all-cause mortality and a smaller reduction in stroke compared with a younger cohort due to increased ICH. What is not known is how treatment affected quality of life, particularly among the very elderly.
This study provides large-scale, contemporary real-world evidence that supports a more individualized approach to selecting direct oral anticoagulants in the very elderly, with findings highly relevant to both general internal medicine and geriatric practice.
Interesting take on risk differences for the very elderly receiving OAC therapies over time. There is net benefit in reducing stroke risk as afib stroke risk goes up with age, but harder to show reduction in death when their older age will always compete with other causes of death and not because the OAC was initiated. Also, in earlier periods, the very elderly patients were receiving OAC at much lower rates in early periods and at much higher rates later with safer DOAC prescribing. Bleeding risk and ICH will always be higher in the very elderly as age itself predicts bleeding and will be higher in those on OAC than not on OAC as a time-based confounder when DOACs were introduced after 2010. Lastly, I would want to see drug and dose data in this very elderly population as under-dosing in the elderly will increase stroke and ICH rates losing efficacy and not benefiting safety. This still suggests benefit for the very elderly, but needs further analysis at the drug and dose level.
A very important study for cardiologists (or others) who are weighing the risks and benefits of DOACs in patients with AF. The results from the subgroup of patients over 85 may be practice-changing, or at least hypothesis-generating.
, McMaster University