Use of anticoagulants in elderly patients: practical recommendations

Figures & data

Table 1 Levels of venous thromboembolism risk and American College of Chest Physicians recommended thromboprophylaxis in hospitalized patients⁸

Level of risk	Approximate DVT risk without thromboprophylaxis, %	Suggested thromboprophylaxis options
Low risk	<10%	No specific thromboprophylaxis, early and aggressive ambulation
Minor surgery in mobile patients
Medical patients who are fully mobile
Moderate risk	10%–40%	LMWH or low-dose UFH (bid or tid) or fondaparinux
Most general, open gynecologic or urologic surgery patients
Medical patients at bed rest or sick
High risk	40%–80%	LMWH or fondaparinux or oral vitamin K antagonist (INR 2.0–3.0)
Hip or knee arthroplasty, hip fracture surgery
Major trauma, spinal cord injury

Notes: For patients with moderate or high thromboembolic risk and high bleeding risk, mechanical prophylaxis with intermittent pneumatic compression devices, or venous foot pump and/or graduate compression stockings are recommended.

Abbreviations: DVT, deep vein thrombosis; INR, international normalized ratio; LMWH, low molecular weight heparins; UFH, unfractionated heparin.

Table 2 Risk of stroke in the National Registry of Atrial Fibrillation (NRAF) participants, stratified by CHADS2 score²³

CHADS2 scorea	Adjusted stroke rate per 100 patient-years (95%CI)
0	1.9 (1.2–3.0)
1	2.8 (2.0–3.8)
2	4.0 (3.1–5.1)
3	5.9 (4.6–7.3)
4	8.5 (6.3–11.1)
5	12.5 (8.2–17.5)
6	18.2 (10.5–27.4)

^aCHADS2 score is calculated by adding 1 point for each of the following: recent congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus; and 2 points for prior stroke or transient ischemic attack.

Table 3 Antithrombotic therapy in nonvalvular atrial fibrillation: American College of Chest Physicians recommendations²⁴

Risk categories	Antithrombotic recommendation	Gradeb
High risk
Chronic or paroxysmal AF, with prior ischemic stroke, TIA or systemic embolism	Long-term VKA INR 2.5 (2.0–3.0)	1A
Chronic or paroxysmal AF and ≥2 risk factorsa	Long-term VKA INR 2.5 (2.0–3.0)	1A
Intermediate risk
Chronic or paroxysmal AF and 1 risk factor*	Long-term VKA INR 2.5 (2.0–3.0) or Aspirin 75–325 mg/day VKA preferred to aspirin	1A 1B 2A
Low risk
Chronic or paroxysmal AF and age ≤ 75 years and no risk factorsa	Long-term aspirin 75–325 mg/day	1B

^a Risk factors: age > 75 years; hypertension; diabetes mellitus; moderately/severely impaired left ventricular systolic function and/or heart failure.

^b Grade 1 (strong recommendation): guideline developers are very certain that benefits do outweigh risks, burden and costs. Grade 2 (weaker recommendation): guideline developers are less certain of the magnitude of benefits and risks, burden and costs. Support for these recommendations comes from high-quality, moderate-quality or low-quality evidence (labelled A, B and C).⁷⁴

Abbreviations: AF, atrial fibrillation; TIA, transient ischemic attack; VKA, vitamin k antagonists.

Table 4 The RIETE Registry bleeding score⁵³

Risk factors	Score
Recent major bleeding	2 points
Creatinine level > 1.2 mg/dL (110 μ mol/L)	1.5 points
Anemia (Hb < 13 (men) or 12 (women) g/dL)	1.5 points
Cancer	1 point
Clinically overt PE	1 point
Age > 75 years	1 point
Rate of major bleeding per 100 patients within 3 months of anticoagulant therapy according to the score:
Score	0	1–4	>4
Rate (%, 95%CI)	0.3 (0.1–0.6)	2.6 (2.3–2.9)	7.3 (5.6–9.3)

Table 5 Risk of major bleeding on warfarin therapy for AF as stratified by HEMORR2HAGES score⁵⁶

HEMORR2HAGES scorea	Major bleeding per 100 person-years (95% CI)
0	1.9 (0.6–4.4)
1	2.5 (1.3–4.3)
2	5.3 (3.4–8.1)
3	8.4 (4.9–13.6)
4	10.4 (5.1–18.9)
≥5	12.3 (5.8–23.1)
Any score	4.9 (3.9–6.3)

^a HEMORR2HAGES score is calculated by adding 1 point for each of the following: Hepatic or renal disease, Ethanol abuse, Malignancy, Older age (>75 years), Reduced platelet count or function, Rebleeding risk (2 points), Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, and Stroke.

Table 6 Suggested regimen for the use of parenteral anticoagulants in patients with renal insufficiency

Creatinine clearance (Cockroft)	Prophylactic anticoagulation	Therapeutic anticoagulation
>50 mL/min	Fondaparinux LMWH	Fondaparinux LMWH
30–50 mL/min	LMWH without dose reduction Fondaparinux without dose reduction	LMWH without dose reduction, anti-Xa level after 3rd or 4th dose, anti-Xa monitoring twice weekly thereafter (NB dose reduction can be considered in this group if creatinine clearance is at the lower limit) UFH Fondaparinux for limited duration of treatment (caution in case of prolonged treatment because of the risk of accumulation)
<30 mL/min	UFH LMWH with dose reduction (1/2 dose), anti-Xa monitoring if prolonged treatment (to make sure there is no accumulation) Fondaparinux contra-indicated	UFH LMWH with dose reduction (1/2 dose), anti-Xa level after the 2nd dose, and minimum twice weekly thereafter Fondaparinux contra-indicated

Abbreviations: LMWH, low molecular weight heparins; UFH, unfractionated heparin.

Table 7 Specific low-dose regimen for initiating warfarin therapy for patients > 70 years⁶⁵

Day	INR value 10 AM	Warfarin dose (mg) 6 PM
Day 0	Do not measure	4
Day 1	Do not measure	4
Day 2	Do not measure	4
		Predicted maintenance dose
Day 3	<1.3	5
	INR ≥ 1.3	4
	INR ≥ 1.5	3
	INR ≥ 1.7	2
	INR ≥ 1.9	1
	INR ≥ 2.5	Measure INR daily and omit doses until INR < 2.5 mg, then give 1 mg

Notes: This algorithm does not apply to patients who have received warfarin within the preceding week of have a pretreatment international normalized ratio (INR) >1.3.

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