Résumé
La fibrillation atriale (FA) est le trouble du rythme le plus fréquent chez la personne âgée. Elle est associée à un risque accru d’accidents vasculaires cérébraux (AVC), de décompensation cardiaque, d’altération de la qualité de vie ainsi qu’à un excès de mortalité. La prévention des AVC cardioemboliques secondaires à la FA représente ainsi un enjeu majeur de santé publique. Le traitement anticoagulant oral par antivitamines K (AVK) a montré depuis plusieurs décennies un rapport bénéfice/risque favorable pour la prévention des AVC cardioemboliques, tout particulièrement chez les personnes âgées qui présentent un risque plus élevé d’AVC en présence d’une FA, comparativement aux sujets plus jeunes. Pourtant, 30 % environ des sujets âgés en FA ne reçoivent pas d’anticoagulation, sans contre-indication apparente. De nouvelles recommandations de la Société européenne de cardiologie émises en 2012 préconisent l’introduction du traitement anticoagulant (AVK ou nouveaux anticoagulants [NACO] dès un score CHA2DS2-VASc égal à 1 [excepté les femmes de moins de 65 ans présentant une FA isolée]). Les NACO sont désormais indiqués en première intention suite aux résultats de plusieurs essais de noninfériorité versus coumadine. Il convient de rappeler qu’aucun de ces essais n’a inclus à ce jour à large échelle des sujets de plus de 80 ans, de surcroît polypathologiques, polymédiqués et présentant des syndromes gériatriques. Dans de telles populations âgées, la prudence est donc de mise (primum non nocere) quant à la prescription des NACO d’autant plus que les personnes âgées concernées présentent un faible poids et/ou une altération de la fonction rénale.
Abstract
Atrial fibrillation (AF) is the most frequently seen heart problem among elderly people. It is associated with an increased risk of cerebral vascular accidents (CVA), cardiac decompensation, worsened quality of life and increased mortality. The prevention of cardio-embolic CVAs secondary to AF therefore represents a major challenge to public health. For several decades now, oral anticoagulants (vitamin K antagonists) have been shown to have a favourable benefit/ risk ratio for the prevention of cardio-embolic CVAs, especially among elderly people who present a higher risk of a CVA with the presence of AF, compared to younger patients. However, around 30% of elderly patients with AF do not receive anticoagulant treatment, with no apparent contraindications. New recommendations from the European Cardiology Society published in 2012 favour the introduction of anticoagulant treatment (vitamin K antagonists or new anticoagulants [NACO] with a CHA2DS2-VASc score equal to 1 [except for women under the age of 65 with an isolated AF]). NACOs are now indicated in first intention following the results of a number of non-inferiority tests versus coumadin. Please note that none of these tests have yet included a wide range of patients over the age of 80, or with multiple pathologies, multiple medical problems or presenting geriatric syndromes. In these elderly demographics, care is therefore taken (first do no harm) regarding the prescription of NACOs where the elderly patients in question have a low body weight and/or altered kidney function.
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Vogel, T., Suna-Enache, C., Andrès, E. et al. La fibrillation atriale chez la personne âgée : actualités de la prise en charge thérapeutique selon les dernières recommandations (2012) de la Société européenne de cardiologie : focus sur le traitement anticoagulant. cah. année gerontol. 5, 245–256 (2013). https://doi.org/10.1007/s12612-013-0355-5
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DOI: https://doi.org/10.1007/s12612-013-0355-5