Key result
In very elderly patients (≥85 years) with atrial fibrillation, DOACs were associated with a lower mortality rate compared to VKAs (HR 0.64), alongside similar bleeding risks but a higher risk of cerebral thrombotic events.
Why the study?
The applicability of clinical trial results on DOACs versus warfarin to very elderly patients with atrial fibrillation aged ≥85 years is uncertain.
Do DOACs reduce mortality, bleeding, and thrombotic rates compared to VKAs in very elderly patients (≥85 years) with atrial fibrillation?
Cohort (n=1,124)
Yes
Do DOACs reduce mortality, bleeding, and thrombotic rates compared to VKAs in very elderly patients (≥85 years) with atrial fibrillation?
In atrial fibrillation patients aged ≥85 years, DOACs were associated with lower mortality but a higher rate of thrombotic events compared to VKAs, with similar bleeding rates.
Answers are grounded in this paper and cite their sources.
May warrant individualized DOAC consideration in very elderly AF despite thrombotic signal; leaves open net benefit confirmation in RCTs.
Direct oral anticoagulants (DOACs) have shown similar efficacy and safety with respect to warfarin in patients with atrial fibrillation (AF). However, the proportion of patients aged ≥85 years enrolled in clinical trials was low and the applicability of their results to very elderly patients is still uncertain. We have carried out a prospective cohort study on AF patients aged ≥85 years enrolled in the Survey on anticoagulaTed pAtients RegisTer (START2-Register) and treated with either VKAs or DOACs, with the aim to evaluate mortality, bleeding and thrombotic rates during a long-term follow-up. We enrolled 1124 patients who started anticoagulation at ≥85 years with VKA (58.7%) or DOACs (41.3%), Clinical characteristics of patients were similar, except for a higher prevalence of coronary artery disease and renal failure in VKAs patients and of a history of previous bleeding and previous stroke/TIA in patients on DOACs. Median CHA2DS2VASc and HAS-BLED scores were similar between the two groups. During follow-up, 47 major bleedings (rate 2.3 x100 pt-yrs) and 19 stroke/TIA (0.9 x100 pt-yrs) were recorded. The incidence of bleeding was similar between patients on VKAs and DOACs. Patients on DOACs showed a higher rate of thrombotic events during treatment (rate 1.84 and 0.50,respectively). Mortality rate was higher in patients on VKAs than in patients on DOACs (HR 0.64 (95% CI 0.46-0.91). In conclusion, we confirm the overall safety and effectiveness of anticoagulant treatment in very elderly AF patients, with lower mortality rates in DOACs patients, similar bleeding risk, and a higher risk for cerebral thrombotic events in DOACs patients.
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Poli et al. (2019) conducted a cohort in Atrial fibrillation (n=1,124). Direct oral anticoagulants (DOACs) vs. Vitamin K antagonists (VKAs) was evaluated on All-cause mortality (HR 0.64, 95% CI 0.46-0.91). In very elderly patients (≥85 years) with atrial fibrillation, DOACs were associated with a lower mortality rate compared to VKAs (HR 0.64), alongside similar bleeding risks but a higher risk of cerebral thrombotic events.
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