Non-valvular atrial fibrillation (NVAF) is more common with increasing age. Doctors are increasingly asked about anticoagulation in such patients.
Is it appropriate to give anticoagulation in patients aged ≥ 90 years with NVAF who are:
a. Ambulatory and having preserved cognition.
b. Partially dependent with impaired cognition and brain CT evidence of lacunar infarcts.
c. On Nosogastric (NGT) or PEG tube feeding with associated Alzheimer's disease and bedridden status.
Any evidence-based answers will be appreciated.
I suggest that you contact
Dr Ahmed H Abdelhafiz [email protected] ;
he is the one who should know.
very difficult to give warfarin through NG tube , not effective , difficult to monitore . I advise no anticoagulation in such patients.
Hi Muhammad,
Thanks for your question, certainly a clinical conundrum encountered increasingly frequently and one for which direct evidence is limited. However, a nice review I read recently summarises this well, particularly the impact that NOAC profiles have on the risk:benefit decision you nicely present:
Article Management of Atrial Fibrillation in Elderly Adults
This article provides a very telling conclusion:
"The literature suggests that elderly adults with AF—even those with high bleeding risk—benefit from anticoagulation. The benefit of anticoagulation appears to be most marked in those with high stroke and bleeding risk, a category into which many elderly adults fall. By reducing the risk of ICH, the DOACs may tip this risk:benefit ratio even further toward anticoagulation."
Hope this helps.
Interesting question!
Nice balance between benefit and risk is need!
You must stimate her CHAD2-VASc (over 75 y: 2 points, and woman: 1 points.. At least 3 points) and HAD-BLEED risk
Case a) Yes
Case b) Probably yes (At least CHAD2-VASc 5 points), It depends of her stability and fall risks. But, why she has not been treated before?
Case c) Probably no. Maybe, low molecular heparin could be the alternative because her bed status. But, please avoid therapeutic incarnation.
There is increasing evidence that even people with advanced age can benefit from OAT, especially with the better safety profile of DOACs. From a geriatrician's perspective, a preventive therapy such as OAT depends not only on thromboembolic risk (evaluated through CHA2DS2-VASc) but also on the overall health and functional status of the patient (i.e. che comprehensive geriatric assessment), helping to identify people who would probably benefit more from the prevention of a thromboembolic stroke (i.e. autonomous in relative good overall health status) from those who does not.
Please see this review we made on the topic
Article Oral anticoagulant therapy for older patients with atrial fi...
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