Editor's Note: Commentary based on Pilotto A, Gallina P, Copetti M, et al. Warfarin treatment and all-cause mortality in community-dwelling older adults with atrial fibrillation: a retrospective observational study. J Am Geriatr Soc 2016;64:1416-24. For accompanying article summary, please see the associated Expert Analysis.

The incidence and prevalence of atrial fibrillation (AF) increase progressively with age, and advanced age is a powerful risk factor for stroke in patients with AF. Moreover, the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) study clearly demonstrated that warfarin substantially reduced the risk of stroke in patients ≥75 years of age, with similar benefits in patients 75-79, 80-84, and ≥85 years of age.¹ Nonetheless, patients enrolled in clinical trials are manifestly different from those encountered in clinical practice, and uncertainty persists about the utility of warfarin (and other anticoagulants) in elderly patients at increased risk for falls, bleeding, and other adverse events. As a result, use of warfarin declines with age, even in the face of very high stroke risk, as defined by the CHADS₂ or CHA₂DS₂-VASc score. The study by Pilotto A et al.,² which was a retrospective analysis of prospectively collected data, provides strong evidence that in very elderly patients with AF, warfarin is associated with substantial reduction in 2-year mortality, even among the frailest and most functionally impaired individuals. Limitations of the current study include the lack of data on other outcomes (e.g., bleeding, strokes, quality of life) and potential for residual confounding (i.e., warfarin-treated patients may have been healthier despite adjusting for measured confounders). The study was conducted in Italy and did not include nursing home residents, so additional studies are needed to confirm these findings in other populations. But these limitations notwithstanding, this study has important implications for clinical practice and supports a more aggressive approach to the use of anticoagulation in elderly patients with AF, even in those with frailty and multimorbidity.

References

1. Mant J, Hobbs R, Fletcher K, et al. Warfarin versus aspirin for stoke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment in the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007;370:493-503.
2. Pilotto A, Gallina P, Copetti M, et al. Warfarin treatment and all-cause mortality in community-dwelling older adults with atrial fibrillation: a retrospective observational study. J Am Geriatr Soc 2016;64:1416-24.

Keywords: Aged, Anticoagulants, Atrial Fibrillation, Blood Coagulation, Comorbidity, Hemorrhage, Nursing Homes, Quality of Life, Retrospective Studies, Risk Factors, Stroke, Warfarin, Geriatrics

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