Contraindications for anticoagulation in older patients with atrial fibrillation; a narrative review

Oral anticoagulation (OAC) is the most effective treatment to prevent strokes in patients with atrial fibrillation (AF). Many older patients are not prescribed OAC.

To explore which co-morbid conditions in older patients with AF have been associated with under-treatment with OAC, or were used as exclusion criteria for trials, or have been associated with increased risk of bleeding.

A Pubmed search was conducted with the terms elderly, atrial fibrillation, stroke risk, bleeding risk, intracranial haemorrhage, cognition, fall risk, renal dysfunction, alcohol abuse, malignancy, polypharmacy, NSAID, under-treatment, under-use and under-prescription.

Higher age is associated with under-treatment. Patients with a higher risk of stroke show higher rates of bleeding complications. The associations of bleeding rates with possible contraindications are inconsistent.

Published bleeding rates reflect selection bias, describing mainly relatively healthy older patients. The use of stratification schemes for stroke risk and for bleeding risk will have to be implemented.

The decision to prescribe OAC in older patients with AF remains a challenging task since bleeding risk is difficult to estimate reliably. Stratification schemes may be helpful.