Lown Right Care
Reducing Overuse and Underuse
Anticoagulation in Older Adults
Am Fam Physician. 2020 Jun 15;101(12):748-750.
Author disclosure: No relevant financial affiliations.
Mr. H is an 84-year-old man with well-controlled hypertension and hyperlipidemia. He recently presented to the emergency department with anxiety symptoms, shortness of breath, and palpitations. A clinical examination found an irregular heart rhythm of 140 to 160 beats per minute. An electrocardiogram (ECG) showed atrial fibrillation with no acute ST-T wave changes. After Mr. H received an intravenous dose of a beta blocker, his heart rate quickly decreased to the 80s, and his symptoms resolved. However, a repeat ECG showed that he was in atrial fibrillation. He was admitted for telemetry monitoring, and an oral beta blocker and intravenous heparin were initiated. Laboratory tests showed no evidence of ischemia, anemia, electrolyte imbalance, or thyroid dysfunction. An echocardiogram showed calcification of the aortic and mitral valves but no stenosis or significant regurgitation. A cardiologist recommended prescribing a direct oral anticoagulant to prevent an embolic stroke. However, Mr. H’s primary care physician is concerned about the risks of anticoagulation because of recent functional decline in the patient, including a slowing of his gait without any falls.
Atrial fibrillation is the most common cardiac arrhythmia, occurring in an estimated 2.7 million to 6.1 million people in the United States.1 Approximately 9% of people 65 years and older have this condition, and it occurs more often in men.2 [corrected]Risk factors include hypertension, diabetes mellitus, ischemic heart disease, and older age. Each year atrial fibrillation causes more than 750,000 hospital admissions and more than 130,000 deaths, often associated with strokes.3 An estimated 15% to 20% of strokes occur in patients with underlying atrial fibrillation.4,5
The use of warfarin (Coumadin) and direct oral anticoagulants such as rivaroxaban (Xarelto), apixaban (Eliquis), and dabigatran (Pradaxa) to prevent strokes is the first-line treatment for younger patients with atrial fibrillation. However, the use of direct oral anticoagulants in older people is problematic because of a higher risk of morbidity and mortality from gastrointestinal and intracerebral bleeding, which can be exacerbated by falls.
Practice guidelines recommend risk stratification with the CHA2DS2-VASc tool (congestive heart failure; hypertension; age 75 years or older [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65 to 74 years; sex category; https://www.mdcalc.com/cha2ds2-vasc-score-atrial-fibrillation-stroke-risk) to identify patients who could benefit from anticoagulation therapy; however, there is a modest predictive ability for ischemic stroke.6–8 Some physicians use the CHA2DS2-VASc tool to determine whether to initiate anticoagulation therapy without considering the patient’s functional status and bleeding risk, which is not recommended. Bleeding risk scores such as HAS-BLED (hypertension, abnormal renal and liver function, stroke history, bleeding risk, labile international normalized ratio, elderly [older than 65 years], drugs and alcohol use; https://www.mdcalc.com/has-bled-score-major-bleeding-risk) may help assess risk but have limited predictive power.
A 2007 Cochrane review evaluated high-quality placebo-controlled studies comparing the benefits and risks of anticoagulation in atrial fibrillation. Participants were younger (average age 69 years) and had less comorbidity than the general population. After two years, patients taking warfarin experienced 17 out of 1,000 fewer strokes (number needed to treat [NNT] = 59) and five out of 1,000 fewer disabling or fatal strokes (NNT = 200). This distinction is essential because most studies assess only the reduction of all strokes, some of which are mild or quickly resolve. Compared with those who received placebo, participants who were treated with warfarin experienced 40 out of 1,000 more severe bleeds (number needed to harm [NNH] = 25), six of which were fatal, and six out of 1,000 more developed hemorrhagic strokes (NNH = 83 for fatal bleeds and hemorrhagic strokes combined). There was no difference in all-cause mortality.9
Few older people are included in randomized controlled trials of anticoagulation; therefore, there are limited data about risks in this population.10,11 A 2018 cohort study examined the risks and benefits of anticoagulation in people 90 years and older. Fifteen out of 1,000 averted strokes with anticoagulation therapy (NNT = 67), and the rate of averting a stroke was similar between warfarin and direct oral anticoagulants. In the direct oral anticoagulant arm, four out of 1,000 had a hemorrhagic stroke vs. 16 out of 1,000 in the warfarin arm. In each group using anticoagulation therapy, approximately 60 out of 1,000 participants had major bleeds.12
It is unclear how often older people with comorbidities that would increase the risk of bleeding (e.g., prior bleeding events, prior reactions
Referencesshow all references
1. Centers for Disease Control and Prevention. Atrial fibrillation. Accessed November 10, 2019. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_atrial_fibrillation.htm...
2. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation [published correction appears in J Am Coll Cardiol. 2014;64(21):2305–2307]. J Am Coll Cardiol. 2014;64(21):e1–e76.
3. Gómez-Outes A, Lagunar-Ruiz J, Terleira-Fernández AI, et al. Causes of death in anticoagulated patients with atrial fibrillation. J Am Coll Cardiol. 2016;68(23):2508–2521.
4. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association [published corrections appear in Circulation. 2015;131(24):e535 and Circulation 2016;133(8):e417]. Circulation. 2015;131(4):e29–e322.
5. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22(8):983–988.
6. Maheshwari A, Norby FL, Roetker NS, et al. Refining prediction of atrial fibrillation–related stroke using the P2-CHA2DS2-VASc score. Circulation. 2019;139(2):180–191.
7. American Academy of Family Physicians. Clinical practice guideline: atrial fibrillation. Accessed March 15, 2020. https://www.aafp.org/patient-care/clinical-recommendations/all/atrial-fibrillation.html
8. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Circulation. 2019;140(2):e125–e151.
9. Aguilar MI, Hart R, Pearce LA. Oral anticoagulants versus antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no history of stroke or transient ischemic attacks. Cochrane Database Syst Rev. 2007;(3):CD006186.
10. Ebell MH. Evaluating the benefits and harms of anticoagulation in patients with atrial fibrillation. Am Fam Physician. 2018;98(12):751–753. Accessed March 10, 2020. https://www.aafp.org/afp/2018/1215/p751.html
11. Wigle P, Hein B, Bernheisel CR. Anticoagulation: updated guidelines for outpatient management. Am Fam Physician. 2019;100(7):426–434. Accessed March 10, 2020. https://www.aafp.org/afp/2019/1001/p426.html
12. Chao TF, Liu CJ, Lin YJ, et al. Oral anticoagulation in very elderly patients with atrial fibrillation: a nationwide cohort study. Circulation. 2018;138(1):37–47.
13. Seelig J, Pisters R, Hemels ME, et al. When to withhold oral anticoagulation in atrial fibrillation – an overview of frequent clinical discussion topics. Vasc Health Risk Manag. 2019;15:399–408.
14. Chiu AS, Jean RA, Fleming M, et al. Recurrent falls among elderly patients and the impact of anticoagulation therapy. World J Surg. 2018;42(12):3932–3938.
15. Sharma M, Cornelius VR, Patel JP, et al. Efficacy and harms of direct oral anticoagulants in the elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism: systematic review and meta-analyses. Circulation. 2015;132(3):194–204.
16. Mitchell A, Watson MC, Welsh T, et al. Effectiveness and safety of direct oral anticoagulants versus vitamin K antagonists for people aged 75 years and over with atrial fibrillation: a systematic review and meta-analyses of observational studies. J Clin Med. 2019;8(4):E554.
17. Bai Y, Guo SD, Deng H, et al. Effectiveness and safety of oral anticoagulants in older patients with atrial fibrillation: a systematic review and meta-regression analysis. Age Ageing. 2018;47(1):9–17.
18. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383(9921):955–962.
19. Vinogradova Y, Coupland C, Hill T, et al. Risks and benefits of direct oral anticoagulants versus warfarin in a real work setting: cohort study in primary care [published correction appears in BMJ. 2018;363:k4413]. BMJ. 2018;362:k2505.
20. Graham DJ, Baro E, Zhang R, et al. Comparative stroke, bleeding, and mortality risks in older Medicare patients treated with oral anticoagulants for nonvalvular atrial fibrillation. Am J Med. 2019;132(5):596–604.
21. Xian Y, Xu H, O’Brien EC, et al. Clinical effectiveness of direct oral anticoagulants vs warfarin in older patients with atrial fibrillation and ischemic stroke: findings from the patient-centered research into outcomes stroke patients prefer and effectiveness research (PROSPER) Study. JAMA Neurol. 2019;76(10):1192–1202.
22. Desai NR, Cornutt D. Reversal agents for direct oral anticoagulants: considerations for hospital physicians and intensivists. Hosp Pract (1995). 2019;47(3):113–122.
Lown Institute Right Care Alliance is a grassroots coalition of clinicians, patients, and community members organizing to make health care institutions accountable to communities and to put patients, not profits, at the heart of health care.
This series is coordinated by Kenny Lin, MD, MPH, deputy editor.
Copyright © 2020 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact email@example.com for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions