Managing older people with atrial fibrillation and preventing stroke: a review of anticoagulation approaches

ABSTRACT

Introduction

Oral anticoagulants (OACs) are the cornerstone of stroke prevention in atrial fibrillation (AF), but prescribing decisions in older people are complicated. Clinicians must assess the net clinical benefit of OAC in the context of multiple chronic conditions, polypharmacy, frailty and life expectancy. The under-representation of high-risk, older adult sub-populations in clinical trials presents the challenge of choosing the right OAC, where a ‘one-size-fits-all’ approach cannot be taken.

Areas covered

This review discusses OAC approaches for stroke prevention in older people with AF and presents a prescribing aid to support clinicians’ decision-making. High-risk older adults with multiple chronic conditions, specifically chronic kidney disease, dementia/cognitive impairment, previous stroke/transient ischemic attack or intracranial hemorrhage, polypharmacy, frailty, low body weight, high falls risk, and those aged ≥75 years are considered.

Expert opinion

Non-vitamin K antagonist OACs are the preferred first-line OAC in older adults with AF, including high-risk subpopulations, after individual assessment of stroke and bleeding risk, except those with mechanical heart valves and moderate-to-severe mitral stenosis. Head-to-head comparisons of NOACs are not available, therefore the choice of drug (and dose) should be based on an individual’s risk (stroke and bleeding) and incorporate their treatment preferences. Treatment decisions must be person-centered and principles of shared decision-making applied.

KEYWORDS:

• Anticoagulants
• atrial fibrillation
• frailty
• multimorbidity
• non-vitamin K antagonist oral anticoagulants
• older people
• stroke
• vitamin K antagonists

Article highlights

• Non-vitamin K antagonist oral anticoagulants (NOACs) are first line for stroke prevention in eligible older people with atrial fibrillation (AF)

• Older people with chronic kidney disease, dementia/cognitive impairment, prior history of stroke/transient ischemic attack or intracranial hemorrhage, polypharmacy, frailty, low body weight and high falls risk should also be considered for NOAC therapy

• The choice of NOAC should be guided by the individual risk assessment, incorporating personal preference and the process of shared decision making should be followed

• In people without capacity, discussions regarding OAC for stroke prevention should be held with a person’s next of kin or Power of Attorney for Health

Declaration of interests

DA Lane has received investigator-initiated educational grants from BMS and Pfizer and is a co-applicant on the AFFIRMO study, a European Union Horizon 2020 research and innovation program funded grant [No. 899871], and has been a speaker for Bayer, Boehringer Ingelheim, and BMS/Pfizer and has consulted for BMS, and Boehringer Ingelheim; all outside the submitted work.

PE Penson owns four shares in AstraZeneca PLC and has received honoraria and/or travel reimbursement for events sponsored by AKCEA, Amgen, AMRYT, Link Medical, Napp, Sanofi.

GYH Lip has been a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Anthos and Daiichi Sankyo; no fees are received personally. He is co-lead on the AFFIRMO study, a European Union Horizon 2020 research and innovation program funded grant [No. 899871].

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A peer reviewer on this manuscript has received speaker and advisory fees from Daiichi Sankyo. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.