Antithrombotic Therapy in the Elderly: ESC Expert Position Paper

Andreotti F, Rocca B, Husted S, et al., on behalf of the ESC Thrombosis Working Group.
Antithrombotic Therapy in the Elderly: Expert Position Paper of the European Society of Cardiology Working Group on Thrombosis. Eur Heart J 2015;Jul 9:[Epub ahead of print].

The following are 10 key points from this European Society of Cardiology Working Group on Thrombosis regarding the use of antithrombotic therapy in elderly patients (ages ≥65-75 years):

  1. Elderly patients are at increased risk of thrombotic disorders, such as acute coronary syndromes (ACS), thromboembolism from atrial fibrillation (AF), and venous thromboembolism (VTE). At the same time, they are at increased bleeding risk when treated with antiplatelet and anticoagulant agents.
  2. Elderly patients should not be denied life-saving antithrombotic medications simply because of advanced age. Rather, an individualized approach to risk-benefit assessment is needed.
  3. Age-related organ changes affect drug pharmacokinetics. For instance, the volume of distribution increases (along with half-life) for lipophilic drugs while it decreases (along with plasma concentrations) for hydrophilic drugs. Similarly, due to changes in liver metabolism, first-pass metabolism of medications is less effective. Last, a decrease in renal blood flow and glomerular filtration rate can impair elimination.
  4. Antiplatelet medications are all approved for use in elderly patients, with some dose adjustments or considerations.
    • Clopidogrel 75 mg daily is recommended for ACS and post-percutaneous coronary intervention (PCI). The 300 mg loading dose should be excluded if fibrinolysis is given for an ST-segment elevation myocardial infarction (STEMI) in patients ≥75 years old.
    • Prasugrel is recommended at a reduce dose of 5 mg daily for patients ≥75 years for PCI in ACS.
    • Vorapaxar 2.5 mg daily dosing is to be used with caution in the elderly for post-MI and peripheral artery disease.
  5. Oral anticoagulants are approved for use in elderly patients with some dose adjustments or considerations.
    • Vitamin K antagonists (e.g., warfarin) can be used for a variety of disorders, but lower doses are usually needed in elderly patients. Closer monitoring is advised.
    • Dabigatran should be used at the 110 mg dose for nonvalvular AF patients ≥80 years, and considered for patients 75-79 years old. It is also approved for use in VTE patients.
    • Apixaban should be dosed at 2.5 mg twice daily if patients are aged ≥80 years and have either low body weight (≤60 kg) or elevated serum creatinine (≥1.5 mg/dl). It is approved for patients with nonvalvular AF and VTE.
  6. Parenteral anticoagulants are approved for use in elderly patients with some dose adjustments or considerations.
    • Low molecular weight heparins are approved for use in a variety of indications, but a reduced dose of 0.75-1.0 mg/kg twice daily should be used in patients aged ≥75 years. Also, use of a 30 mg intravenous bolus should be avoided when fibrinolysis is being administered in elderly patients.
  7. Fibrinolytic agents are approved for use in elderly patients with some dose adjustments or considerations.
    • Tenecteplase can be used for STEMI and acute pulmonary embolism patients. A half-dose strategy for STEMI patients is advised for patients ≥75 years.
  8. Preventing bleeding in elderly patients treated with antithrombotic therapies is important. Strategies may include avoiding or shortening the duration of “triple therapy” (aspirin, P2Y12-inhibitor, and an anticoagulant) whenever possible, avoiding surgery while on antithrombotic medications, use of radial over femoral access for PCI, use of proton pump inhibitors in patients on dual antiplatelet medications, and avoidance of nonsteroidal anti-inflammatory medications and steroids whenever possible.
  9. Minor or nuisance bleeding and minor interventions (cutaneous, percutaneous, dental, and endoscopic) should not be cause for interrupting appropriate antithrombotic medications.
  10. After an intracranial hemorrhage, resuming antithrombotic therapy should be considered with great caution. In AF patients, consideration of left atrial appendage occlusion is reasonable.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and ACS, Anticoagulation Management and Venothromboembolism, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and ACS, Interventions and Vascular Medicine

Keywords: Acute Coronary Syndrome, Arrhythmias, Cardiac, Anticoagulants, Aspirin, Fibrinolysis, Fibrinolytic Agents, Geriatrics, Intracranial Hemorrhages, Myocardial Infarction, Percutaneous Coronary Intervention, Peripheral Arterial Disease, Platelet Aggregation Inhibitors, Proton Pump Inhibitors, Pulmonary Embolism, Risk Assessment, Venous Thromboembolism

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