Direct oral anticoagulant use and the incidence of bleeding in the very elderly with atrial fibrillation
- 1.4k Downloads
Atrial fibrillation (AF) is a major risk factor for stroke in the elderly population. The use of anticoagulation in patients with AF greatly reduces the risk for stroke, but results in an increased risk of bleeding. Over the past several years, direct oral anticoagulants (DOACs, dabigatran, rivaroxaban, and apixaban) have been used in place of warfarin for stroke prevention in AF. We conducted a retrospective cohort study to assess the safety of DOACs in very elderly patients (75+) managed in a health care system encompassing both community and academic settings. We found that 36 % of patients had moderate to severe renal failure (estimated glomerular filtration rate <59 ml/min/1.73 m2) at the time of DOAC initiation. 142 patients were followed for a mean of 2.56 years, and five experienced a major bleeding episode while on anticoagulation, for a rate of 1.37 per 100 person years. All major bleeding episodes were associated with a decline in GFR compared to baseline. There were 12 non-major bleeding episodes reported. HAS-BLED scores were similar for those patients who experienced bleeding complications compared to those who did not. 21 % of patients were prescribed an inappropriately low dose of DOAC based on approved recommendations. DOACs appear to be a safe form of anticoagulation in very elderly patients with AF. However, the decline in GFR among patients with major bleeding highlights the importance of routine renal function monitoring.
KeywordsDirect oral anticoagulants Rivaroxaban Dabigatran Apixaban Elderly Bleeding Atrial fibrillation
Funding for Fatima Khan, M.B.B.S., was supported by National Institutes of Health T32 Hematology research training Grant (5T32HL00706). Research reported in this publication was supported in part by Grant number UL1TR000114 from the National Center for Advancing Translational Sciences of the National Institutes of Health. The clinical data was provided by the University of Minnesota’s Informatics Consulting Service.
Compliance with ethical standards
Financial disclosures and conflicts of interest
All authors declare no conflicting financial interest.
This study was conducted with the approval of the University of Minnesota Institutional Review Board.
- 2.Reiffel JA (2014) Atrial fibrillation and stroke: epidemiology. Am J Med 127(4):e15–e16Google Scholar
- 8.Halperin JL et al (2014) Efficacy and safety of rivaroxaban compared with warfarin among elderly patients with nonvalvular atrial fibrillation in the rivaroxaban once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation (ROCKET AF). Circulation 130(2):138–146CrossRefPubMedGoogle Scholar
- 11.Lip GY et al (2011) Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, drugs/alcohol concomitantly) score. J Am Coll Cardiol 57(2):173–180CrossRefPubMedGoogle Scholar
- 22.Gladstone DJ et al (2015) How to monitor patients receiving direct oral anticoagulants for stroke prevention in atrial fibrillation: a practice tool endorsed by thrombosis Canada, the Canadian Stroke Consortium, the Canadian Cardiovascular Pharmacists Network, and the Canadian Cardiovascular Society. Ann Intern Med 163(5):382–385CrossRefPubMedGoogle Scholar