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Published on: February 26, 2013
Antithrombotic therapy for atrial fibrillation and coronary artery disease in older patients
Connie N Hess1, Samuel Broderick, Jonathan P Piccini
1Duke Clinical Research Institute, Durham, NC 27705, USA.
Insights
Older patients with atrial fibrillation and coronary artery disease need careful antithrombotic therapy. Warfarin use was low, even in high-risk elderly patients, and did not improve outcomes.
Area of Science:
- Cardiology
- Geriatrics
- Pharmacology
Background:
- Older adults with atrial fibrillation (AF) and coronary artery disease (CAD) have elevated risks of stroke and bleeding when treated with antithrombotics.
- Balancing the benefits and risks of aspirin, clopidogrel, and warfarin is crucial in this demographic.
Purpose of the Study:
- To analyze antithrombotic prescribing patterns in elderly patients with both AF and CAD.
- To evaluate the association between antithrombotic strategies and clinical outcomes in this high-risk population.
Main Methods:
- A cohort of patients aged 65 and older with AF and confirmed CAD was identified from the Duke Databank for Cardiovascular Disease (2000-2010).
- Antithrombotic use (aspirin, clopidogrel, warfarin) was assessed in relation to stroke risk (CHADS(2) score) and bleeding risk (ATRIA score).
- 1-year adjusted outcomes, including death and the composite of death, myocardial infarction, or stroke, were analyzed by treatment strategy.
Main Results:
- The study included 2,122 patients, with 22.5% aged 80 or older. Acute coronary syndromes were present in 53.4% of patients.
- Warfarin use was 38.9% overall. Patients aged 80+ had higher stroke risk (84.7% vs 57.8%) and bleeding risk (55.8% vs 23.3%) compared to those 65-79.
- Warfarin use increased with higher stroke risk but decreased with higher bleeding risk. Only 38.2% of patients 80+ with high stroke risk received warfarin. Antithrombotic strategy did not significantly impact 1-year outcomes.
Conclusions:
- Warfarin utilization remains low among elderly patients with AF and CAD.
- Even among the oldest patients (≥80 years) with the highest stroke risk, warfarin prescribing rates were similar to the overall cohort.
- Further research is needed to optimize antithrombotic therapy for this vulnerable patient group.
Background:
Older patients with atrial fibrillation (AF) and coronary artery disease (CAD) face high risk of stroke and bleeding with antithrombotic therapy. Balancing safe and effective use of aspirin, clopidogrel, and warfarin in this population is important.
Methods:
From the Duke Databank for Cardiovascular Disease, we identified patients with AF ≥65 years old with angiographically confirmed CAD from 2000 to 2010. Antithrombotic use was described across age and Congestive heart failure, Hypertension, Age >75 years, Diabetes, prior Stroke/transient ischemic attack (CHADS(2)) stroke risk and Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) bleeding scores. Death and the composite of death, myocardial infarction, and stroke by antithrombotic strategy were reported.
Results:
Of 2,122 patients ≥65 years old with AF and CAD, 477 (22.5%) were ≥80 years old; 1,133 (53.4%) had acute coronary syndromes. Overall rates of aspirin, clopidogrel, and warfarin use were 83.4%, 34.6%, and 38.9%, respectively. Compared with patients 65 to 79 years old, more patients ≥80 years old were at high stroke risk (CHADS(2) ≥2, 84.7% vs 57.8%) and high bleeding risk (ATRIA 5-10, 55.8% vs 23.3%). Warfarin use in both age groups increased with higher CHADS(2) scores and decreased with higher ATRIA scores. Of patients ≥80 years old with CHADS(2) ≥2, 150 (38.2%) received warfarin. Antithrombotic strategy was not associated with improved 1-year adjusted outcomes.
Conclusions:
Among older patients with AF and CAD, overall warfarin use was low. Patients ≥80 years old at highest stroke risk received warfarin in similar proportions to the overall cohort. Further investigation into optimizing antithrombotic strategies in this population is warranted.
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