Antithrombotic therapy in very elderly patients with atrial fibrillation: is it enough to assess thromboembolic risk?

Although attention has been given to thromboprophylaxis for atrial fibrillation (AF) in present treatment guidelines, practical, clinical antithrombotic therapy is poorly developed for very elderly patients. We reviewed the records of 105 consecutive patients with AF of mean age 85 years, to determine how the greatest benefits from antithrombotic therapy could be obtained in this group. The mean CHADS2 score in these patients was 3.1 +/- 1.5. Before antithrombotic therapy, 21.0% of the patients had diseases with a risk of hemorrhage, 26.7% had diseases with a risk of thrombosis, and 8.6% had diseases with a risk of both hemorrhage and thrombosis. Moreover, 89 patients (84.8%) were receiving a single antiplatelet drug, 10 (9.5%) used aspirin plus clopidogrel, and six (5.7%) were taking an oral anticoagulant (OAC). Additionally, dual antiplatelet therapy was more commonly given to patients with permanent AF (paroxysmal and persistent versus permanent, 6.3% and 12.5% versus 30%, respectively, Chi-square = 8.4, P = 0.010). The incidence of adverse events was 25.7%, with thromboembolic events in 20.0% and hemorrhage in 5.7% of patients. There were no thromboembolic events in those patients taking OACs, but 33% of patients who took OACs had bleeding complications. It is difficult to choose appropriate antithrombotic strategies in very elderly patients. Both the thrombotic risk and the bleeding risk should be considered for helping such patients derive optimal benefit from thromboprophylaxis for AF.