Antithrombotic Therapy in Older Adults: Key Points

Andreotti F, Geisler T, Collet JP, et al.
Acute, Periprocedural and Long-Term Antithrombotic Therapy in Older Adults: 2022 Update by the ESC Working Group on Thrombosis. Eur Heart J 2022;Dec 7:[Epub ahead of print].

The following are key points to remember from this update by the European Society of Cardiology (ESC) Working Group on Thrombosis regarding acute, periprocedural, and long-term antithrombotic therapy in older adults:

  1. Pharmacological and nonpharmacological strategies are recommended to improve medical adherence in older adults. These include deprescribing, polypill use, reminder tools, and educational interventions.
  2. Although antithrombotic therapy in elderly patients with cardiovascular disease (CVD) yields a net clinical benefit given the increased thrombotic risk with age, systematic bleeding risk assessment is recommended.
  3. For secondary CVD prevention, the benefit vs. risk profile of long-term low-dose aspirin vs. no antiplatelet therapy is favorable in older and younger patients.
  4. In patients ≥75 years of age, the long-term risk of disabling or fatal bleeding with antiplatelet therapy is higher than in younger patients, with half of the major bleeding being upper gastrointestinal. Therefore, routine proton pump inhibitor therapy is recommended.
  5. For primary CVD prevention, among adults aged ≥70 years without evidence of atherosclerotic disease, current data indicate an unfavorable benefit–risk balance for long-term low-dose aspirin therapy. Therefore, its use is generally not recommended.
  6. The balance of efficacy-to-safety should drive P2Y12 inhibitor therapy choice following acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI). For patients with PCI-treated ACS aged ≥75 years, reduced-dose prasugrel (5 mg daily) or use of clopidogrel is recommended, while patients with chronic coronary syndrome (CCS) treated by PCI are recommended to receive clopidogrel. Use of dual antiplatelet therapy (DAPT) is generally discouraged for >12 months following PCI in patients aged ≥75 years, and can be as short as 1 month in high bleeding risk patients.
  7. In older patients with ACS and/or PCI, it is reasonable to avoid P2Y12 inhibitor use pre-angiogram (unless ST-segment elevation myocardial infarction [STEMI]), de-escalating from ticagrelor or prasugrel to clopidogrel or low-dose prasugrel, or use single antiplatelet therapy (e.g., aspirin, clopidogrel, ticagrelor) after 1-3 months of DAPT in an effort to reduce bleeding risk.
  8. For older patients with atrial fibrillation (AF) and ACS or undergoing PCI, dual antithrombotic therapy with a direct oral anticoagulant (DOAC) plus clopidogrel is advisable after a short course (1-4 weeks) of triple antithrombotic therapy. For older patients with AF and CCS not undergoing PCI, DOAC monotherapy is advisable.
  9. For older patients not currently using a P2Y12 inhibitor who present for PCI, intravenous cangrelor is a reasonable option periprocedurally. Intravenous glycoprotein IIb/IIIa inhibitor (GPI) therapy is usually limited to emergency bailout or perioperative bridging for high ischemic risk patients.
  10. For elderly patients with STEMI or non-ST segment elevation ACS, unfractionated heparin or enoxaparin is generally administered when immediate PCI is planned. Fondaparinux is preferable in the absence of severe chronic kidney disease when the patient is managed conservatively.
  11. For older patients with STEMI who are unable to undergo primary PCI within 120 minutes from diagnosis, systemic fibrinolysis is advised with tenecteplase dose adjustment for age.
  12. For older patients with CCS or peripheral artery disease (PAD) at high risk of ischemic events but not high bleeding risk, dual pathway inhibition with low-dose aspirin and very low-dose rivaroxaban (2.5 mg twice daily) is reasonable.
  13. Advanced age should not be a reason for underuse of oral anticoagulation in patients with AF. DOACs are generally preferred to vitamin K antagonists (VKAs) unless the patient has a mechanical valve, severe chronic kidney disease, or mitral stenosis.
  14. For patients with AF at high bleeding risk who are undergoing left atrial appendage closure, short-term oral anticoagulation (e.g., 45 days) or 1-6 months of DAPT (aspirin plus clopidogrel) followed by single antiplatelet therapy or no antiplatelet therapy are reasonable options.
  15. For older patients undergoing transcatheter aortic valve implantation, single antiplatelet therapy is preferable to DAPT. When oral anticoagulant is required, monotherapy is recommended rather than combination anticoagulation-antiplatelet therapy. DOACs are preferred over VKA when patients are eligible.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Valvular Heart Disease, Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and SIHD, Cardiac Surgery and VHD, Interventions and ACS, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Chronic Angina

Keywords: Acute Coronary Syndrome, Anticoagulants, Arrhythmias, Cardiac, Aspirin, Atrial Appendage, Atrial Fibrillation, Cardiac Surgical Procedures, Geriatrics, Heart Valve Diseases, Hemorrhage, Heparin, Kidney Diseases, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Proton Pump Inhibitors, Risk, Secondary Prevention, ST Elevation Myocardial Infarction, Transcatheter Aortic Valve Replacement, Thrombosis, Vascular Diseases, Vitamin K

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