title: Thromboembolic prevention in frail elderly patients with atrial fibrillation: a practical algorithm.
abstract: Atrial fibrillation is a common condition in the elderly, and the incidence of thromboembolic events secondary to atrial fibrillation increases with age. Antithrombotic therapy effectively prevents stroke and systemic embolism but also exposes patients to the risk of bleeding. Because the risk of bleeding also increases with age, clinicians tend to withhold anticoagulation in the elderly. Anticoagulation is particularly complex in the frail elderly patient, who presents additional risk factors affecting both efficacy and safety of thromboembolic prevention. The main clinical trials rarely include frail elderly patients and, consequently, the guidelines do not provide guidance for their management. In the absence of clear indications for this class of patients, we identified some areas that should be taken into account both before starting and when discontinuing anticoagulation: comorbidities, polypharmacotherapy, adherence, cognitive impairment, mobility and monitoring barriers, nutritional status and swallowing disorders, risk of falls, and reduced life expectancy. We also suggest a multidimensional algorithm covering both a standard ischemic and bleeding risk assessment and an additional anticoagulation-focused frailty assessment. This is of particular relevance given the recent introduction of the oral direct inhibitors, as they are likely to widen the treatment options for the frail elderly. Depending on which aspect of frailty is present, anticoagulation can now be tailored accordingly.
authors: University of Padova, Department of Medicine- DIMED, Padova, Italy; King's College Hospital, London, United Kingdom. Electronic address: serena.granziera@gmail.com.
authors: Serena
authors: S
authors: Granziera
authors: Department of Thrombosis and Hemostasis, Guy's and St Thomas' Hospitals, London, United Kingdom.
authors: Alexander T
authors: AT
authors: Cohen
authors: University of Padova, Department of Medicine- DIMED, Padova, Italy.
authors: Giovanni
authors: G
authors: Nante
authors: University of Padova, Department of Medicine- DIMED, Padova, Italy.
authors: Enzo
authors: E
authors: Manzato
authors: University of Padova, Department of Medicine- DIMED, Padova, Italy. Electronic address: giuseppe.sergi@unipd.it.
authors: Giuseppe
authors: G
authors: Sergi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000889:Anti-Arrhythmia Agents / Q000008:administration & dosage*; D000925:Anticoagulants / Q000008:administration & dosage; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D002545:Brain Ischemia / Q000209:etiology / Q000517:prevention & control*; D018849:Controlled Clinical Trials as Topic; D005260:Female; D016330:Frail Elderly / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D013923:Thromboembolism / Q000209:etiology / Q000517:prevention & control*
chemical_list: D000889:Anti-Arrhythmia Agents; D000925:Anticoagulants
keywords: Elderly; atrial fibrillation; bleeding risk; frailty; oral anticoagulants; stroke prevention