Anticoagulation in Very Old Patients with Atrial Fibrillation (AVOPA): A Descriptive Observational Study

In older patients with nonvalvular atrial fibrillation, oral anticoagulation is challenging, especially among very old patients. Even though positive effects of oral anticoagulation have been described in this age group (> 85 years), there is still a high rate of inappropriate dosing.

This study examines the quality of care for very old hospitalized patients. The aims of this study were to (1) describe the percentage of patients receiving oral anticoagulation at discharge, (2) describe the quality of drug management at discharge, regarding dosing and contraindications, and (3) provide additional data towards establishing a benchmark for the quality of care in very old patients with atrial fibrillation.

This study is a single-center descriptive observational study. The data from 407 patients aged > 85 years who were hospitalized in 2018 with nonvalvular atrial fibrillation were collected retrospectively from the patient charts. The assessment included specific geriatric aspects, such as falls, the Charlson Comorbidity Index, and nursing categorization.

During hospitalization, the proportion of anticoagulated patients increased from 57.5% (n = 234) to 67.3% (n = 274). We found an increasing trend in the use of direct oral anticoagulants, with an increase from 39.8% (n = 162) to 46.2% (n = 188). Regarding the quality of drug management, 13.8% (n = 56) of the patients were not anticoagulated even in the absence of a recognizable contraindication, whereas a contraindication was ignored in only 0.8% (n = 2 out of 188). Dosing was appropriate among all patients taking rivaroxaban, edoxaban, and dabigatran. The dose of apixaban was not reduced in 23.6% (n = 21 out of 89), although this dose reduction was necessary according to the dose adjustment criteria. An underdose of a direct oral anticoagulant was found in 26.1% of the patients (n = 49 out of 188).

Compared to the results reported in the literature, the percentage of very old patients with atrial fibrillation receiving anticoagulants was high. During hospitalization, the proportion of patients receiving a direct oral anticoagulant increased, which was in contrast to the trend in the proportion of patients taking phenprocoumon. Our results could help to find a benchmark for anticoagulation management among hospitalized very old patients.