CLINICAL QUESTION

In people 80 years and older taking a direct oral anticoagulant (DOAC), who is at increased risk for major hemorrhage?

EVIDENCE SUMMARY

DOACs have a somewhat lower bleeding risk than older vitamin K antagonists such as warfarin. DOACs are also more convenient to take, which make them well suited for older patients. Current guidelines recommend DOACs over warfarin for patients who require anticoagulation for atrial fibrillation.^1,2 However, the risk of major hemorrhage increases with age, and older patients may consider alternative therapies, such as left atrial appendage closure, if they have a significantly higher risk of bleeding.³ Therefore, a score to predict bleeding risk in patients 80 years and older is needed to guide shared decision-making.

Several risk scores have been developed and prospectively validated to predict the likelihood of major bleeding in patients taking anticoagulation, including the HAS-BLED, HEMORR₂HAGES, ATRIA, and ORBIT risk scores.^4–7 However, these risk scores were developed in younger populations with mean ages of 71 to 76 years; in some cases, they have a large number of predictors that increases the burden for clinicians to apply them.⁵