Direct Oral Anticoagulant Use in Older Adults with Atrial Fibrillation: Challenges and Solutions

AF is the most common arrhythmia in clinical practice, with a large preponderance in the older (>75 years) adult population. Stroke is the most feared complication of AF, with huge corresponding morbidity and mortality. Anticoagulation is the mainstay for stroke prevention in AF, but is commonly underutilised in clinical practice due to the fear of intracerebral bleeding. Bleeding is the primary concern in older patients with conventional vitamin K antagonist use. Direct oral anticoagulants (DOACs) have been used for a decade in clinical practice and have been found to reduce major bleeds. The advantages of DOAC use in older patients include obviating the need for intermittent international normalised ratio monitoring, fewer drug interactions and reduction in intracerebral haemorrhage. The disadvantages of DOAC use include older patients having to take multiple doses per day and a lack of a universal antidote, as opposed to vitamin K antagonists. However, a lack of head-to-head trials among DOACs and specific randomised controlled trials in older patients preclude a definite conclusion regarding the ideal DOAC that should be used in the older population. Factor XI inhibition is an emerging approach for oral anticoagulation that holds promise for dissociating thrombosis from haemostasis. This provides an additional avenue for reducing bleeding in the older adult population.