What Drives Anticoagulant Selection in Patients Aged ≥85 Years with Atrial Fibrillation? Insights from the CRAFT...

Background: Anticoagulation management in very elderly patients with atrial fibrillation (AF) is particularly challenging due to the coexistence of high thromboembolic and bleeding risks, often compounded by multiple comorbidities. Randomized clinical trials rarely include patients aged ≥85 years, leaving important gaps in our understanding of how anticoagulant therapies are selected in this growing population. Methods: We analyzed data from the CRAFT registry, including 2914 patients hospitalized with AF. Patients were stratified into two age groups: <85 years (n = 2322) and ≥85 years (n = 592). Baseline clinical characteristics, comorbidities, and laboratory parameters were compared between groups. Separate multivariable logistic regression analyses were performed for each age group to identify independent predictors of anticoagulant therapy selection. Results: Patients aged ≥85 years exhibited a distinct clinical profile, characterized by higher thromboembolic risk and a greater prevalence of heart failure, renal dysfunction, anemia, and structural heart disease. Renal function was significantly impaired (median eGFR 47.6 vs. 60.0 mL/min; p < 0.001), while NT-proBNP levels were higher and hemoglobin levels lower in this group. Multivariable analysis revealed clear age-related differences in determinants of treatment selection. In patients < 85 years, anticoagulant choice was influenced by multiple clinical factors, including CHA₂DS₂-VA score, renal function, bleeding risk, coronary artery disease, and prior revascularization. In contrast, in patients ≥ 85 years, only two independent predictors remained significant: thromboembolic risk (CHA₂DS₂-VA score; OR 1.34, 95% CI 1.11-1.64) and renal function (eGFR; OR 0.64, 95% CI 0.47-0.89). Anticoagulation in this group was predominantly based on reduced-dose DOACs, with apixaban used most frequently. Conclusions: Very elderly patients with AF represent a clinically distinct, high-risk population. While anticoagulant selection in younger elderly patients reflects a multifactorial decision process, treatment in those aged ≥85 years appears to rely primarily on thromboembolic risk and renal function, suggesting a more streamlined-and potentially oversimplified-approach.