scholarly journals Anticoagulation therapy in the elderly with non-valvular atrial fibrillation: a double-edged sword

2017 ◽  
Vol 3 (2) ◽  
Author(s):  
Francesco Vetta ◽  
Gabriella Locorotondo ◽  
Giampaolo Vetta
Keyword(s):  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Anticoagulant Therapy ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Treatment Strategies ◽  
The Elderly ◽  
Hemorrhagic Events

Prevalence of non-valvular atrial fibrillation is increasing over time. Particularly in elderly population, treatment strategies to reduce the rate of stroke are challenging and still represent an unsolved cultural question. Indeed, the risk of thromboembolism increases in the elderly in parallel with the risk of bleeding. The frequent coexistence of several morbidities, frailty syndrome, polypharmacy, chronic kidney disease and dementia strengthens the perception that risk-benefit ratio of anticoagulant therapy could be unfavorable, and explains why such treatment is underused in the elderly. Recently, the introduction of non-vitamin K oral anticoagulants (NOACs) has allowed us to overcome the large number of limitations imposed by the use of vitamin K antagonists. In this manuscript, the benefits of individual NOACs in comparison with warfarin in elderly patients are reviewed. Targeted studies on complex elderly patients are needed to test usefulness of a geriatric comprehensive assessment, besides the scores addressing risk of thromboembolic and hemorrhagic events. In the meantime, it is mandatory that use of anticoagulant therapy in most elderly people, currently excluded from randomized controlled trials, is prudent and responsible.

scholarly journals Net clinical benefit of anticoagulation therapy in the elderly patients with atrial fibrillation

2018 ◽  
Vol 88 (2) ◽  
Author(s):  
Lorenzo Palleschi ◽  
Eleonora Nunziata
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Clinical Decision Making ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Clinical Decision ◽  
The Elderly ◽  
Thromboembolic Disease ◽  
Net Clinical Benefit

Old age remains one of the strongest risk factors for stroke in patients with atrial fibrillation (AF). Oral anticoagulation (OAC) is the most effective way to prevent thromboembolic disease in patients with atrial fibrillation (AF). Until few years ago, aspirin and vitamin-K antagonists (VKAs) were the primary agents used to prevent thromboembolic disease in patients with AF. The approval of non–vitamin K oral anticoagulants (NOACs) has now expanded the range of therapeutic agents available to providers. The authors highlight practical considerations regarding the selection and use of OAC in older adults to aid clinical decision making.

scholarly journals Anticoagulation in Atrial Fibrillation Cardioversion: What Is Crucial to Take into Account

2021 ◽  
Vol 10 (15) ◽  
pp. 3212
Author(s):  
Fabiana Lucà ◽  
Simona Giubilato ◽  
Stefania Angela Di Fusco ◽  
Laura Piccioni ◽  
Carmelo Massimiliano Rao ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Thrombus Formation ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Significant Advance ◽  
Thromboembolic Events ◽  
Thromboembolic Risk ◽  
Pharmacological Cardioversion

The therapeutic dilemma between rhythm and rate control in the management of atrial fibrillation (AF) is still unresolved and electrical or pharmacological cardioversion (CV) frequently represents a useful strategy. The most recent guidelines recommend anticoagulation according to individual thromboembolic risk. Vitamin K antagonists (VKAs) have been routinely used to prevent thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) represent a significant advance due to their more predictable therapeutic effect and more favorable hemorrhagic risk profile. In hemodynamically unstable patients, an emergency electrical cardioversion (ECV) must be performed. In this situation, intravenous heparin or low molecular weight heparin (LMWH) should be administered before CV. In patients with AF occurring within less than 48 h, synchronized direct ECV should be the elective procedure, as it restores sinus rhythm quicker and more successfully than pharmacological cardioversion (PCV) and is associated with shorter length of hospitalization. Patients with acute onset AF were traditionally considered at lower risk of thromboembolic events due to the shorter time for atrial thrombus formation. In patients with hemodynamic stability and AF for more than 48 h, an ECV should be planned after at least 3 weeks of anticoagulation therapy. Alternatively, transesophageal echocardiography (TEE) to rule out left atrial appendage thrombus (LAAT) should be performed, followed by ECV and anticoagulation for at least 4 weeks. Theoretically, the standardized use of TEE before CV allows a better stratification of thromboembolic risk, although data available to date are not univocal.

scholarly journals Dabigatran in the ischemic patient undergoing atrial fibrillation ablation

ABOUTOPEN ◽  
2018 ◽  
Vol 4 (1) ◽  
pp. 154-157
Author(s):  
Roberto Spoladore
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Anticoagulant Therapy ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Poor Response ◽  
Rf Ablation ◽  
Ablation Procedure ◽  
Total Period ◽  
Hemorrhagic Events

Trans-catheter ablation of atrial fibrillation (AF) is a common treatment for symptomatic AF. Among the major complications of AF ablation are stroke, transient ischemic attacks and peri-procedural cardiac tamponade. Various clinical trials have shown that uninterrupted treatment with vitamin K antagonists (VKA) is associated with a lower incidence of embolic events compared to discontinuation of therapy; until recently, in the absence of equally solid evidence, this practice was not extended to the new oral anticoagulants (NOAC) not VKA due to the fear of hemorrhagic complications potentially associated with the use of an "irreversible" anticoagulant. The case of a patient suffering from numerous comorbidities is reported here. In light of the poor response to anti-arrhythmics, a TC-RF ablation was performed, with suspension of dabigatran administration only on the day of the procedure (for a total period <24 hours). Although the fear of the risk of bleeding potentially associated with the trans-catheter ablation procedure may still induce clinicians to stop anticoagulant therapy, even the decision to discontinue anticoagulant therapy with dabigatran on the day of surgery alone is challenged by recent evidence in the literature supporting the efficacy of dabigatran in reducing the incidence of hemorrhagic events during and after ablation, including the results of the RE-CIRCUIT study (Cardiology)

scholarly journals 2021 Korean Heart Rhythm Society Guidelines for Stroke Prevention in Atrial Fibrillation

2021 ◽  
Vol 96 (4) ◽  
pp. 296-311
Author(s):  
Ki Hong Lee ◽  
Jin-Bae Kim ◽  
Seung Yong Shin ◽  
Boyoung Joung
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Optimal Strategies ◽  
Mechanical Valve ◽  
Heart Rhythm ◽  
Bleeding Risk

Atrial fibrillation (AF) is a strong risk factor for ischemic stroke and systemic embolism. To prevent thromboembolic events in patients with AF, anticoagulation therapy is essential. The anticoagulant strategy is determined after stroke and bleeding risk assessments using the CHA2DS2-VASc and HAS-BLED scores, respectively; both consider clinical risk factors. Vitamin K antagonists (VKAs) are the sole anticoagulant option in AF patients with a prosthetic mechanical valve or moderate-severe mitral stenosis; in all other AF patients VKA or non-vitamin K antagonist oral anticoagulants are therapeutic options. However, antiplatelet therapy should not be used for stroke prevention in AF patients. Anticoagulation is not needed in AF patients with low stroke risk but strongly recommended in those with a with low bleeding risk. Left atrial appendage (LAA) occlusion offers an alternative in AF patients in whom long-term anticoagulation is contraindicated. Surgical occlusion or the exclusion of LAA can be considered for stroke prevention in AF patients undergoing cardiac surgery. In this article, we review existing data for stroke prevention and suggest optimal strategies to prevent stroke in AF patients.

Reduced dose of rivaroxaban and dabigatran vs. vitamin K antagonists in very elderly patients with atrial fibrillation in a nationwide cohort study

EP Europace ◽  
2019 ◽  
Author(s):  
Laurent Fauchier ◽  
Patrick Blin ◽  
Frédéric Sacher ◽  
Caroline Dureau-Pournin ◽  
Marie-Agnès Bernard ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Real Life ◽  
European Medicines Agency ◽  
Very Elderly ◽  
Clinical Events ◽  
First Time

Abstract Aims The real-life benefits and risks of the non-vitamin K antagonist oral anticoagulants for stroke prevention in very elderly patients with atrial fibrillation (AF) are still debated. Methods and results Cohorts of new users of rivaroxaban 15 mg, dabigatran 110 mg, or vitamin K antagonists (VKA) for AF ≥85 years old in 2013 or 2014 were identified in the nationwide French claims database and followed-up for 1 year. Cohorts were compared after 1:1 matching using high-dimensional propensity score. Compared to VKA use and considering 1-year cumulative incidences, risk of stroke, and systemic embolism was not different with rivaroxaban use [hazard ratio 1.14, 95% confidence interval (CI): 0.93–1.40] and lower with dabigatran use (0.77, 95% CI: 0.60–0.99), risk of major bleeding was not different with rivaroxaban use (0.91, 95% CI: 0.74–1.11) and with dabigatran use (0.81, 95% CI: 0.64–1.03), risk of all-cause death was borderline to significance lower with rivaroxaban use (0.91, 95% CI: 0.83–1.00), and lower with dabigatran use (0.87, 95% CI: 0.78–0.97). The risk for a composite of all events above was not different with rivaroxaban use (0.96, 95% CI: 0.88–1.04) and lower with dabigatran use (0.87, 95% CI: 0.79–0.96) as compared with VKA use. The risk for the composite of all events was not different with rivaroxaban use as compared with dabigatran use (1.09, 95% CI: 0.97–1.23). Conclusion This study shows for the first time in more than 25 000 new real-life anticoagulant users for AF aged ≥85 years a neutral overall benefit-risk of rivaroxaban 15 mg vs. VKA and a favourable overall benefit-risk of dabigatran 110 mg vs. VKA on relevant clinical events. Study registration European Medicines Agency EUPAS14567 (www.encepp.eu) and Clinicaltrials.gov id NCT02864758.

Atrial Fibrillation and Malignancy: The Clinical Performance of Non–Vitamin K Oral Anticoagulants—A Systematic Review

2018 ◽  
Vol 45 (02) ◽  
pp. 205-214 ◽  
Author(s):  
Roberta Bottino ◽  
Anna Rago ◽  
Pierpaolo Micco ◽  
Antonio D' Onofrio ◽  
Biagio Liccardo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Systematic Review ◽  
Vitamin K ◽  
Clinical Performance ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Therapeutic Anticoagulation ◽  
Increased Risk ◽  
Active Cancer

AbstractAtrial fibrillation (AF) is commonly diagnosed in the setting of active cancer. Because of an increased risk of either thromboembolic events or bleeding, the decision to initiate therapeutic anticoagulation in patients with active cancer can be challenging. Moreover, little is still known about the optimal anticoagulation therapy in the setting of AF and cancer, and no guidelines are as yet available. Considering that nonvitamin K antagonist oral anticoagulants (NOACs) are recommended as alternatives to vitamin K antagonists for stroke prevention in AF patients with CHA2DS2-VASc score ≥2, the authors performed a systematic review of the current literature to describe the efficacy and safety of NOACs in AF patients with malignancy.

Voorkamerfibrillatie en niet-vitamine K-antagonist orale anticoagulantia: van klinische studies tot gebruik in de dagelijkse praktijk

2021 ◽  
Author(s):  
A. CAPIAU ◽  
M. GRYMONPREZ ◽  
T. DE BACKER ◽  
S. GEVAERT ◽  
K. BOUSSERY ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Practice ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Real Life ◽  
Vitamin K Antagonist ◽  
Fixed Dose ◽  
Stroke Risk Factor

Atrial fibrillation and non-vitamin K antagonist oral anticoagulants: from clinical trials to real-world clinical practice. For decades, vitamin K antagonists (VKAs) were the only oral anticoagulants available for the prevention of thromboembolism in patients with atrial fibrillation (AF). Since 2012, non-vitamin K antagonist oral anticoagulants (NOACs) are available for this indication, which have proven to be at least as effective and safe as VKAs in randomized controlled trials (RCTs). NOACs have additional benefits, such as a fast onset of action, a fixed-dose regimen without requiring regular monitoring, less interactions and less intracranial bleeding. Their emergence has caused a paradigm shift in anticoagulation therapy, with NOACs being the anticoagulant of choice compared to VKAs. Since strict in- and exclusion criteria were used in the pivotal RCTs, concerns have risen regarding the generalizability of these results to real-life clinical practice in patients with multiple comorbidities. In this manuscript, this extrapolation is discussed, focusing on 4 different topics regarding appropriate NOAC use: the management of AF patients with a single stroke risk factor, the importance of an optimal therapy adherence, potential drug-drug interactions with NOACs and addressing a geriatric AF patient after a fall. Hopefully, this manuscript will help guide clinicians in the optimal use of NOACs in their daily clinical practice.

scholarly journals Laboratory bleeding predictors in elderly patients with atrial fibrillation taking direct oral anticoagulants

2020 ◽  
pp. 40-43
Author(s):  
M. A. Gabitova ◽  
P. M. Krupenin ◽  
A. A. Sokolova ◽  
D. A. Napalkov ◽  
V. V. Fomin
Keyword(s):  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Anticoagulant Therapy ◽  
Patient Monitoring ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Laboratory Methods ◽  
Increased Risk ◽  
Hemorrhagic Events ◽  
Clinically Significant

Atrial fibrillation (AF) is one of the most common arrhythmias in patients ≥75 years of age. The increased risk of thrombosis due to age and the large number of concomitant diseases makes it evident that anticoagulant therapy is necessary. However, the same factors increase the risk of hemorrhagic complications, which are among the most dangerous side effects of anticoagulant therapy. That is why it is very important to identify patients with the highest probability of bleeding, whether large or small clinically significant and minor. The purpose of our study was to study the prognostic value of laboratory methods of examination with regard to the development of hemorrhagic events in elderly patients with AF taking direct oral anticoagulants (DOAC). The study enrolled 102 patients ≥75 years of age with AF of non-valve etiology taking dabigatran, apixaban, rivaroxaban at full or reduced doses. Anticoagulants were administered by outpatient and inpatient physicians. Both previous experience with DOAC prior to inclusion in the trial (if DOAC was previously prescribed) and prospective patient monitoring after inclusion in the trial were analyzed. The minimum analyzed period of DOAC intake was 18 months. Patients who underwent (n = 19) and did not undergo (n = 83) hemorrhagic events (all events were considered small by ISTH criteria) did not differ in any of the laboratory indicators potentially considered as predictors of hemorrhagic events.

P4793Comparing the effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in the elderly Asian patients with atrial fibrillation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T F Chao ◽  
J N Liao ◽  
G Y H Lip ◽  
S A Chen
Keyword(s):  
Atrial Fibrillation ◽  
Adverse Events ◽  
Elderly Patients ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Lower Risk ◽  
Oral Anticoagulants ◽  
The Elderly ◽  
Vitamin K Antagonist ◽  
Research Database

Abstract Background Stroke prevention in elderly patients with atrial fibrillation (AF) can be challenging. Comparisons of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in the elderly, at different age strata (age 65–74, 75–89, ≥90) in the daily practice have not been well described, particularly in Asians. We aimed to assess the clinical outcomes of NOACs compared warfarin for stroke prevention in elderly patients with AF. Methods A total of 64,169 AF patients aged ≥65 years receiving NOACs or warfarin prescription were identified from the Taiwan National Health Insurance Research Database. The risks of adverse events were compared between NOACs and warfarin in all patients age ≥65 and specifically, with different age strata; that is 65–74 years, 75–89 years and >90 years. Results Overall NOACs were associated with a significantly lower risk of ischemic stroke (adjusted hazard ratio [aHR] 0.869, 95% confidence interval [CI] 0.812–0.931), ICH (aHR 0.524, 95% CI 0.456–0.601), major bleeding (aHR 0,824, 95% CI 0.776–0.875), mortality (aHR 0.511, 95% CI 0.491–0.532) and composite adverse events (aHR 0.646, 95% CI 0.625–0.667) compared to warfarin. There was heterogeneity in treatment effect for NOACs versus warfarin in different age strata, but the results still favored NOACs even among the very elderly (>90 years). The absolute risk difference and reductions in ICH and composite adverse events with NOAC use were even greater among the elderly compared to warfarin (Figure). Conclusions Compared to warfarin, NOACs were associated with a significantly lower risk of adverse events, with heterogeneity in treatment effects among different age strata. Overall, the clear safety signal in favor of NOACs over warfarin was evident irrespective of age strata, being most marked in the most elderly.

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