Quality of direct oral anticoagulant therapy in elderly patients with non-valvular atrial fibrillation

To the Editor,

I read the recent paper by Grant et al. with great interest [1]. Authors report deficiencies in the quality of direct oral anticoagulant (DOAC) treatment in elderly patients with non-valvular atrial fibrillation (NVAF). Significant portion of patients did not have recommended baseline laboratory investigations or timely clinical follow-up after DOAC initiation. Previous ‘real-world’ studies report that underdosing of DOACs is common in elderly patients [2]. The encouraging finding in the current study is that, only 4.3% of patients are prescribed an inappropriate DOAC dose. The study is informative and provides valuable data about DOAC use in elderly patients.

Laboratory monitoring is not required with the DOACs, and patient compliance is better with DOACs than warfarin, yet elderly patients require great care when prescribing DOACs. The results of the multicenter and international randomized clinical trials (RCT) prove the efficacy of DOAC use in patients with NVAF. The study findings suggest that issues remain in the transfer of evidence from the RCTs to the routine clinical practice of DOAC use in elderly patients. In patients of 75 years of age and older, there are limited safety data available on the use of DOACs. Furthermore, populational differences exist, and experience from individual centers can lead the clinician into a more informed view.

The shorter half-life DOACs compared to warfarin indicates that the efficacy of DOACs depends on the adherence and close follow up [3]. A French nationwide cohort study of patients with NVAF suggests that adherence to DOACs is poor in the real-life setting [4].

In conclusion, despite encouraging results from large RCTs, challenges remain about DOACs use in NVAF. Institutional assessment of quality for the DOAC use is therefore crucial, in developing effective strategies to improve outcome in elderly patients with NVAF.