In older patients with atrial fibrillation, NOACs showed superior effectiveness for stroke or systemic embolism (HR 0.83; 95% CI 0.74-0.94) compared to VKAs, with non-inferior safety.
Systematic Review
Do NOACs reduce stroke/systemic embolism and mortality compared to VKAs in older patients with atrial fibrillation?
In older patients with atrial fibrillation, NOACs (particularly apixaban) offer superior stroke prevention and mortality reduction with non-inferior major bleeding risk compared to VKAs.
Hazard Ratio: 0.83 (95% CI 0.74–0.94)
BACKGROUND AND OBJECTIVE: Atrial fibrillation (AF), the most common cardiac arrhythmia, typically increases with age. Oral anticoagulants (OACs) are the cornerstone of treatment to reduce the associated risk for systemic thromboembolism. Four large randomized controlled trials (RCTs) have shown that non-vitamin K antagonist oral anticoagulants (NOACs) are non-inferior to vitamin K antagonists (VKAs) in preventing stroke and systemic embolism, as well as regarding their risk for major bleeding. However, as vulnerable geriatric patients with AF were largely underrepresented in these trials, physicians are faced with the challenge of choosing the right anticoagulant for geriatric patients in real-life clinical practice. In this vulnerable patient group, NOACs tend to be underused or underdosed due to concerns of excessive fall-related intracranial bleeding, cognitive impairment, multiple drug-drug interactions, low body weight or impaired renal function. As life expectancy continues to rise worldwide, the number of geriatric patients substantially increases. Therefore, there is an urgent need for a critical appraisal of the added value of NOACs in geriatric patients with AF at high thromboembolic and bleeding risk. METHODS AND RESULTS: analyses of RCTs and 6 longitudinal observational cohort studies, highlighting the superior effectiveness (hazard ratio (HR) 0.83, 95% confidence interval (CI) 0.74-0.94 for stroke/SE; HR 0.77, 95%CI 0.65-0.92 for mortality) and non-inferior safety (HR 0.93, 95%CI 0.86-1.01 for major bleeding; HR 0.58, 95%CI 0.50-0.67 for intracranial bleeding; HR 1.17, 95%CI 0.99-1.38 for gastrointestinal bleeding) of NOACs versus VKAs in older AF patients. CONCLUSION: Across geriatric subgroups, apixaban was consistently associated with the most favourable benefit-risk profile and should therefore be preferred in geriatric patients with AF. However, research gaps on the impact of increased falling risk, frailty and baseline dementia were identified, requiring careful consideration while awaiting more results.
Grymonprez et al. (Wed,) conducted a systematic review in Atrial Fibrillation. Non-vitamin K antagonist oral anticoagulants (NOACs) vs. Vitamin K antagonists (VKAs) was evaluated on Stroke/systemic embolism (HR 0.83, 95% CI 0.74-0.94). In older patients with atrial fibrillation, NOACs showed superior effectiveness for stroke or systemic embolism (HR 0.83; 95% CI 0.74-0.94) compared to VKAs, with non-inferior safety.