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[Anticoagulation in permanent atrial fibrillation after 75 years of age]
1Service de médecine interne 2, CHU La Cavale-Blanche, 29200 Brest, France. armelle.gentric@chu-brest.fr
Insights
Anticoagulant therapy is underutilized in patients over 75 with nonvalvular atrial fibrillation, despite proven stroke risk reduction. Current guidelines may overestimate treatment risks, necessitating a re-evaluation of the risk-benefit ratio for this population.
Area of Science:
- Geriatric Medicine
- Cardiology
- Neurology
Context:
- Nonvalvular permanent atrial fibrillation affects over 10% of individuals aged 75+
- This condition is a significant risk factor, contributing to at least 30% of ischemic strokes
- Elderly patients over 75 face a high annual stroke risk exceeding 8%
Purpose:
- To discuss the use of anticoagulant therapy in patients over 75 with nonvalvular permanent atrial fibrillation
- To evaluate anticoagulant therapy for primary/secondary stroke prevention and in the acute stroke phase
- To address the underutilization of anticoagulation in this demographic
Summary:
- Vitamin K antagonists (e.g., warfarin) effectively reduce stroke risk by approximately 68% in patients over 75 with atrial fibrillation when INR is maintained between 2 and 3
- Aspirin's efficacy for stroke prevention has not been established in this elderly population
- Initiating anticoagulation in the acute phase of stroke is generally not recommended; however, venous thrombosis prevention is crucial
Impact:
- Less than 30% of patients over 75 with nonvalvular permanent atrial fibrillation currently receive anticoagulant therapy
- The perceived risks of anticoagulant treatment in the elderly may be overestimated
- A more precise evaluation of the risk-benefit ratio is essential for optimizing patient care and stroke prevention
Purpose:
More than 10% of the population over 75 years old is concerned by non valvular permanent atrial fibrillation which is responsible for at least 30% of ischemic strokes. The indication of an anticoagulant therapy is discussed in two different situations: primary or secondary prevention of stroke and acute phase of stroke.
Current Knowledge And Key Points:
Patients over 75 years old have a high risk of stroke (> 8% year). All the studies have demonstrated the benefit of a primary or secondary prevention by antivitamin K with an INR between 2 and 3 (reduction of the relative risk of about 68%). Conversely, the efficacy of aspirin has not been proven in this population of elderly patients. Once stroke has occurred, it is not recommended to initiate an anticoagulation (unfractioned or low molecular weight heparin) within the first hours. Prevention of venous thrombosis remains necessary.
Future Prospects And Projects:
Currently, less than 30% of the patients older than 75 years are given anticoagulation, the risk of the treatment being probably overestimated. The risk benefit ratio should be evaluated more properly for a given patient.