Efficacy and safety of direct oral anticoagulants in older adults with atrial fibrillation: a prospective single-centre cohort study

IntroductionDirect oral anticoagulants (DOACs) are underused in the elderly, regardless the evidence in their favour in this population.MethodsWe prospectively enrolled anticoagulant-naive patients aged & GE; 75 years who started treatment with DOACs for atrial fibrillation (AF) and stratified them in older adults (aged 75-84 years) and extremely older adults (& GE; 85 years). Thrombotic and hemorrhagic events were evaluated for 12 months follow-up.ResultsWe enrolled 518 consecutive patients. They were mostly aged 75-84 years (299 patients; 57.7%) vs. & GE; 85 years (219 patients; 42.3%). Extremely older adults showed higher incidence of all the endpoints (systemic cardioembolism [HR 3.25 (95% CI 1.71-6.18)], major bleeding [HR 2.75 (95% CI 1.77-4.27)], and clinically relevant non-major bleeding [HR 2.13 (95% CI 1.17-3.92)]) vs. older adults during the first year after starting anticoagulation. In patients aged & GE; 85 years, no difference in the aforementioned endpoints was found between those receiving on-label vs. off-label DOACs. In the extremely older adults, chronic kidney disease, polypharmacy, use of antipsychotics, and DOAC discontinuation correlated with higher rates of thrombotic events, whereas a history of bleeding, Charlson Index & GE; 6, use of reduced DOAC dose, absence of a caregiver, use of non-steroidal anti-inflammatory drugs (NSAIDs), and HAS-BLED score & GE; 3 were associated with major bleedings.ConclusionsNaive patients aged & GE; 85 who started a DOAC for AF are at higher risk of thrombotic and bleeding events compared to those aged 75-84 years in the first year of therapy. History of bleeding, HAS-BLED score & GE; 3 and use of NSAIDs are associated with higher rates of major bleeding.

Automated summary

Direct oral anticoagulants (DOACs) are underused in the elderly population, despite the evidence supporting their use. In this study, anticoagulant-naive patients aged 75 years and above were prospectively enrolled and stratified into older adults (aged 75-84 years) and extremely older adults (85 years and above). The results showed that extremely older adults had a higher incidence of thrombotic and hemorrhagic events compared to older adults in the first year of DOAC therapy. Several factors were associated with an increased risk of these events in both age groups.