TY - JOUR
T1 - Thromboprophylaxis in the oldest old with atrial fibrillation
T2 - Between Scylla and Charybdis
AU - Mannucci, Pier Mannuccio
PY - 2013/6
Y1 - 2013/6
N2 - Within a few decades half of the patients with non-valvular atrial fibrillation (AF) will be older than 80 years. These patients are at particularly high risk of thromboembolism (Scylla) but also of the hemorrhagic complications of thromboprophylaxis (Charybdis). A frequent compromise is to use as antithrombotic agents instead of vitamin-K antagonists aspirin or other antiplatelet drugs, which are ineffective for thromboprophylaxis in the oldest old and definitely not free from a high risk of severe bleeding. All the new direct anticoagulants currently licensed (dabigatran, rivaroxaban, apixaban) are at least as effective as warfarin for thromboprophylaxis in AF, but the risk of the intracranial bleeding, the most feared complication of anticoagulant therapy, is at least halved. In the oldest patients of 80 years of age or more preliminary data, available so far only for dabigatran, indicate that the favorable outcomes of direct anticoagulants are also present in this subgroup, often left untreated for fear of intracranial bleeding. The choice between the different direct anticoagulants is driven by the presence or not of renal insufficiency, the presence and degree of multimorbidity and polypharmacy and by the likelihood or not of poor treatment adherence in patients who are often frail and with some degree of cognitive impairment.
AB - Within a few decades half of the patients with non-valvular atrial fibrillation (AF) will be older than 80 years. These patients are at particularly high risk of thromboembolism (Scylla) but also of the hemorrhagic complications of thromboprophylaxis (Charybdis). A frequent compromise is to use as antithrombotic agents instead of vitamin-K antagonists aspirin or other antiplatelet drugs, which are ineffective for thromboprophylaxis in the oldest old and definitely not free from a high risk of severe bleeding. All the new direct anticoagulants currently licensed (dabigatran, rivaroxaban, apixaban) are at least as effective as warfarin for thromboprophylaxis in AF, but the risk of the intracranial bleeding, the most feared complication of anticoagulant therapy, is at least halved. In the oldest patients of 80 years of age or more preliminary data, available so far only for dabigatran, indicate that the favorable outcomes of direct anticoagulants are also present in this subgroup, often left untreated for fear of intracranial bleeding. The choice between the different direct anticoagulants is driven by the presence or not of renal insufficiency, the presence and degree of multimorbidity and polypharmacy and by the likelihood or not of poor treatment adherence in patients who are often frail and with some degree of cognitive impairment.
KW - Apixaban
KW - Atrial fibrillation
KW - Dabigatran etexilate
KW - Rivaroxaban
KW - Vitamin K antagonists
UR - http://www.scopus.com/inward/record.url?scp=84878276945&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84878276945&partnerID=8YFLogxK
U2 - 10.1016/j.ejim.2013.02.001
DO - 10.1016/j.ejim.2013.02.001
M3 - Article
C2 - 23499350
AN - SCOPUS:84878276945
VL - 24
SP - 285
EP - 287
JO - European Journal of Internal Medicine
JF - European Journal of Internal Medicine
SN - 0953-6205
IS - 4
ER -