LITMIR.BIZ

CHAPTER 25 When to anticoagulate, and which anticoagulant?

       Irene Criado Martin1, Alba Mª Costa Grille2, and Roberto Petidier Torregrossa2

      ¹ Geriatrics Department, Hospital of Sant Joan de Deu, Palma de Mallorca, Spain

      ² Geriatrics Department, University Hospital of Getafe, Madrid, Spain

Introduction

      The higher risk in older patients of diseases such acute venous thromboembolism (VTE) and atrial fibrillation (AF), and their higher VTE/AF‐related morbidity, mortality, and cost of care, promote a higher use of anticoagulants for prophylaxis and treatment.

      As life expectancy increases and the proportion of adults age 65 and older rises, it is likely that the burden of thrombotic disease in elderly adults will become even greater. But actual guidelines and recommendations commonly extrapolate study results from younger patients to the sicker elderly because elderly multimorbid patients are underrepresented in many randomized and nonrandomized clinical studies of VTE¹ and AF.²

      Many landmark clinical trials of VTE prophylaxis and treatment excluded patients with an increased bleeding risk, renal failure, or recent stroke. In the last century, several prospective cohort studies and registries, such as the RIETE registry,³ the Elderly Patients followed by Italian Centres for Anticoagulation (EPICA) study,⁴ and the SWIss venous Thromboembolism Cohort (SWITCO65+)⁵ have been carried out to study short‐ and long‐term clinical outcomes in older patients with VTE.

      AF is a major risk for thrombotic disease, and many patients with AF are managed with anticoagulation for primary or secondary prevention of these events. Nonetheless, studies specifically designed in the elderly population are not yet available, and the current evidence excludes multimorbidity patients, polypharmacy, geriatric syndromes and evaluates benefits using health indicators with low clinical impact in this population.^6–8 In addition, the mean age of the patients included in clinical trials is 5 to 10 years younger than the mean age of real‐life patients with non‐valvular atrial fibrillation (NVAF). Because of that, the current guidelines cannot make strong recommendations for individuals 85 years of age or older.^9,10 In an effort to solve this lack of evidence, data from subgroup phase III pivotal trials have been used, including over 30,000 patients older than 75, to demonstrate the efficacy of direct oral anticoagulants (DOACs) in comparison to vitamin K antagonists (VKAs), showing an equal safety profile in older and younger people^11–13. The ARISTOPHANES (Anticoagulants for Reduction in Stroke: Observational Pooled analysis on Health Outcomes and Experience of Patients [NCT03087487]) study aimed to provide complementary information for older patients (age ≥80) by evaluating and comparing the rates of stroke/systemic embolism and major bleeding among NVAF patients newly prescribed apixaban, dabigatran, rivaroxaban, or warfarin.¹⁴ Additionally, extracted data from two large real‐world prospective European registries (PREFER in AF and Prefer in AF PROLONGATION¹⁵) evaluated the net clinical benefit at one year with DOACs versus VKAs; the results showed that major bleeding with DOACs was also lower in higher‐risk patients with low body mass index or age ≥85.¹⁶

This family of oral anticoagulants has been available in Europe since 2011 with different therapeutic indications: (i) prevention of VTE in adult patients who have undergone elective hip or knee replacement surgery; (ii) prevention of stroke and systemic embolism in adult patients with non‐valvular atrial fibrillation (NVAF), and one or more risk factors (such as prior stroke or transient ischaemic attack [TIA]), age ≥75, hypertension, diabetes mellitus, or symptomatic heart failure (NYHA Class ≥II); and (iii) treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and prevention of recurrent DVT and PE in adults. The emergence of this novel oral anticoagulant offers patients and providers options to consider beyond warfarin.¹⁷ Decision‐making should address safety, tolerability, efficacy, price, simplicity of use, and patient preference, so decisions should be individualized for each patient.

The elderly are more prone to thromboembolism

      The

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