Oral Anticoagulation for AF Patients Aged ≥90 Years

Study Questions:

What are the risks of ischemic stroke and intracranial hemorrhage (ICH) in very elderly patients treated with oral anticoagulation (OAC)?


The authors used the Taiwan National Health Insurance Research Database to explore the risk of ischemic stroke and ICH in 11,064 patients with atrial fibrillation (AF) and 14,658 patients with AF who are aged ≥90 years. AF patients were subdivided into three groups: 1) no treatment, 2) antiplatelet therapy only, and 3) warfarin anticoagulation between 1996 and 2011. AF patients treated with OAC between 2012 and 2015 were divided based on treatment with warfarin or nonvitamin K antagonist oral anticoagulants (NOACs).


Compared to patients without AF, AF patients had an increased risk of ischemic stroke (5.75%/year vs. 3.00%/year; hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.74-2.14) and a similar risk of ICH (0.97%/year vs. 0.54%/year; HR, 0.85; 95% CI, 0.66-1.09). Among AF patients, warfarin use, as compared to no treatment, was associated with a lower risk of stroke (3.83%/year vs. 5.75%/year; HR, 0.69; 95% CI, 0.49-0.96) and no difference in ICH risk. When compared to warfarin, AF patients treated with NOACs had a lower risk of ICH (0.42%/year vs. 1.63%/year; HR, 0.32; 95% CI, 0.10-0.97), but no difference in ischemic stroke risk.


The authors concluded that among very elderly patients with AF, OAC use is superior to no therapy and that NOACs have less ICH risk than warfarin.


This study demonstrates similar findings from many prior observational and randomized trials of OAC use in younger AF patients. Specifically, it is reassuring to see that the net clinical benefit of OAC use, and the safety of NOACs versus warfarin is seen even in the most elderly patients. Clinicians should not consider age alone as a contraindication to OAC use in patients with AF.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Brain Ischemia, Geriatrics, Hemorrhage, Intracranial Hemorrhages, Platelet Aggregation Inhibitors, Risk, Secondary Prevention, Stroke, Thrombolytic Therapy, Vascular Diseases, Warfarin

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