Key result
DOAC therapy in AF patients ≥90 years yielded a 1.3% 1-year stroke/TIA rate and 4.4% major bleeding rate, with HAS-BLED showing poor bleeding discrimination (AUC 0.49; 95% CI 0.38-0.60).
Why the study?
Very elderly patients with AF are underrepresented in randomized DOAC trials, leaving limited evidence on real-world stroke protection and the performance of bleeding risk scores at extreme age.
Do direct oral anticoagulants reduce thromboembolic risk compared to predicted rates and does the HAS-BLED score accurately discriminate major bleeding risk in patients aged ≥90 years with atrial fibrillation?
Cohort (n=480)
No
Do direct oral anticoagulants reduce thromboembolic risk compared to predicted rates and does the HAS-BLED score accurately discriminate major bleeding risk in patients aged ≥90 years with atrial fibrillation?
In atrial fibrillation patients aged ≥90 years, DOAC therapy is associated with a much lower thromboembolic rate than predicted by CHA2DS2-VASc, while the HAS-BLED score poorly discriminates individual major bleeding risk at this extreme age.
Answers are grounded in this paper and cite their sources.
DOACs were associated with low stroke rates in AF patients ≥90 years; leaves open whether HAS-BLED retains value for bleeding prediction in this age group.
Background Very elderly patients with atrial fibrillation (AF) carry high predicted thromboembolic risk yet are underrepresented in randomised trials of direct oral anticoagulants (DOACs). Evidence on real-world stroke protection at extreme age and the performance of bleeding risk scores in this setting remains limited. Purpose To evaluate thromboembolic and major bleeding outcomes in DOAC-treated AF patients aged ≥90 years, contextualise observed 1-year event rates against CHA2DS2-VASc and HAS-BLED–based expected risks, and assess HAS-BLED discrimination for major bleeding. Methods Retrospective single-centre cohort study at Meir Medical Center (Israel) including consecutive AF patients aged ≥90 years treated with DOACs between 2016–2021. Follow-up started at DOAC initiation and continued until end of follow-up or death. Outcomes were stroke/transient ischaemic attack (TIA) and major bleeding. Event rates were reported as incidence per 100 person-years and cumulative 1-year rates. HAS-BLED performance was assessed by AUC for 1-year bleeding and Harrell’s C-index; association with bleeding was tested using Cox regression. Results The cohort included 480 patients (mean age 93.0±2.6 years; 63.5% women), mean CHA2DS2-VASc 4.7±1.2 and mean HAS-BLED 2.6±0.7. Over 1556 person-years (median follow-up 2.9 years), stroke/TIA occurred in 31 patients (2.0 per 100 person-years) with a 1-year rate ~1.3%, markedly lower than the ~5–6% annual risk expected without anticoagulation. Major bleeding occurred in 49 patients (3.15 per 100 person-years) with a 1-year rate 4.4%, consistent with the ~4–6% annual risk expected from HAS-BLED. HAS-BLED showed poor discrimination (AUC 0.49; 95% CI 0.38–0.60; C-index 0.47) and was not associated with major bleeding (HR per point 0.80; 95% CI 0.54–1.19; p=0.29). All-cause mortality was high (85.0%). Conclusion In AF patients aged ≥90 years, DOAC therapy was associated with substantially lower observed thromboembolic risk than predicted by CHA2DS2-VASc, while major bleeding remained clinically relevant. HAS-BLED demonstrated limited ability to discriminate individual bleeding risk at extreme age, supporting the need for geriatric-informed risk assessment to guide anticoagulation decisions.
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Hay et al. (2026) conducted a cohort in Atrial fibrillation (n=480). Direct oral anticoagulants (DOACs) vs. Predicted risk from CHA2DS2-VASc and HAS-BLED scores was evaluated on Stroke/transient ischaemic attack (TIA) and major bleeding (HR 0.80, 95% CI 0.54-1.19, p=0.29). DOAC therapy in AF patients ≥90 years yielded a 1.3% 1-year stroke/TIA rate and 4.4% major bleeding rate, with HAS-BLED showing poor bleeding discrimination (AUC 0.49; 95% CI 0.38-0.60).
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