Use of Direct-Acting Oral Anticoagulants in Nonagenarians: A Call for More Data

The prevalence and embolic risk of atrial fibrillation (AF) increase with age. Vitamin K antagonists (VKAs) or direct-acting oral anticoagulants (DOACs) reduce the risk of stroke or embolism. The aim of this review was to summarize the paucity of information regarding the safety and efficacy of DOACs in AF patients aged 90 years or older. The maximum age of included patients is not listed in any of the available DOAC investigating trials and registries, thus it is unclear if nonagenarians were included. Additionally, we could not find any subgroup analysis addressing this issue. There is an urgent need to collect more information on the safety and efficacy of oral anticoagulants in nonagenarians, especially regarding the role of DOACs, which are increasingly prescribed to this group of patients despite the lack of data. The best solution to this problem would be a prospective, randomized trial in this group of patients, however that would require a large investment of time, effort, and funds. In the meantime, we suggest subgroup analyses addressing the effects and safety of VKAs versus DOACs in nonagenarians, in case they have been included in previously completed or ongoing trials or registries. This could be feasible and would be desirable in view of the large amount of data already accumulated. Irrespective of age, anemia in patients receiving DOACs should be carefully investigated to rule out occult blood loss. With their known interaction profile and the possibility of monitoring these drugs, VKAs should be favored over DOACs in nonagenarians until more data are available regarding the safety of DOACs.