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Optimizing Anticoagulation in Older Patients with Nonvalvular Atrial Fibrillation

  • Arrhythmias (J.Bunch, Section Editor)
  • Published:
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Abstract

Purpose of Review

We sought to review the current issues on optimization of anticoagulation in elderly patients with nonvalvular atrial fibrillation (NVAF).

Recent Findings

Advanced age is a risk factor for stroke and as one advances in age, the risk of stroke also increases. One of the many challenges of oral anticoagulation for stroke prevention in the elderly patients with NVAF is the underutilization of anticoagulants. Commonly cited reasons for hesitation by physician in prescribing oral anticoagulants are advanced age, increase risk of bleeding, and the difficulty in maintaining an adequate time in therapeutic range and the need for frequent monitoring for those who are given warfarin. The non-vitamin K antagonist oral anticoagulants (NOAC) have been shown to have similar or superior efficacy, and a better safety profile compared with warfarin due to its wider therapeutic window, low interaction with food, and less frequent monitoring of anticoagulation levels. It is also important to note that renal dysfunction is becoming increasingly common in elderly patients with AF. This poses a therapeutic challenge for physicians due to a higher bleeding risk; thus, renal function should be taken into consideration when prescribing NOACs. Warfarin, on the other hand, remains to be a viable therapeutic option in certain clinical scenarios.

Summary

In elderly patients, the choice of oral anticoagulants for stroke prevention in NVAF should be individualized and should include considerations for the best estimate of absolute benefit weighed against bleeding risks in order to optimize anticoagulation.

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Abbreviations

AF:

Atrial fibrillation

CrCl:

Creatinine clearance

ICH:

Intracranial hemorrhage

INR:

International normalized ratio

NOAC:

Non-vitamin K antagonist oral anticoagulants

NVAF:

Nonvalvular AF

OAC:

Oral anticoagulant

RCT:

Randomized controlled trial

SPAF:

Stroke prevention in atrial fibrillation

TTR:

Time within therapeutic range

VKA:

Vitamin K antagonist

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Authors and Affiliations

  1. Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan

    Abigail Louise D. Te, Tze-Fan Chao & Shih-Ann Chen

  2. Heart Institute, St. Luke’s Medical Center - Global City, Taguig, Philippines

    Abigail Louise D. Te

  3. Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan

    Tze-Fan Chao & Shih-Ann Chen

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Te, A.L.D., Chao, TF. & Chen, SA. Optimizing Anticoagulation in Older Patients with Nonvalvular Atrial Fibrillation. Curr Cardiovasc Risk Rep 13, 3 (2019). https://doi.org/10.1007/s12170-019-0599-8

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