Anticoagulation for Stroke Prevention in Older Adults with Atrial Fibrillation and Comorbidity: Current Evidence and Treatment Challenges

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Abstract

The burden of atrial fibrillation (AF) is projected to increase substantially over the next decade in parallel with the aging of the population. The increasing age, level of comorbidity, and polypharmacy will complicate the treatment of older adults with AF. For instance, advanced age and chronic kidney disease have been shown to increase the risk of both thromboembolism and bleeding in patients with AF. Frailty, recurrent falls and polypharmacy, while very common among elderly patients with AF, are often overlooked in the clinical decision making despite their significant interaction with oral anticoagulant (OAC) and profound impact on the patient's clinical outcomes. Such factors should be recognized, evaluated and considered in a comprehensive decision-making process. The introduction of non-vitamin K oral anticoagulants has radically changed the management of AF allowing for a more individualized selection of OAC. An understanding of the available data regarding the performance of each of the available OAC in a variety of at risk patient populations is paramount for the safe and effective management of this patient population. The aim of this review is to appraise the current evidence, point out the gaps in knowledge, and provide recommendations regarding stroke prevention in older adults with AF and comorbid conditions.

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Stroke and bleeding in atrial fibrillation with chronic kidney disease.

Jonas Olesen, Gregory Lip, Anne-Lise Kamper … (2012)

Both atrial fibrillation and chronic kidney disease increase the risk of stroke and systemic thromboembolism. However, these risks, and the effects of antithrombotic treatment, have not been thoroughly investigated in patients with both conditions. Using Danish national registries, we identified all patients discharged from the hospital with a diagnosis of nonvalvular atrial fibrillation between 1997 and 2008. The risk of stroke or systemic thromboembolism and bleeding associated with non-end-stage chronic kidney disease and with end-stage chronic kidney disease (i.e., disease requiring renal-replacement therapy) was estimated with the use of time-dependent Cox regression analyses. In addition, the effects of treatment with warfarin, aspirin, or both in patients with chronic kidney disease were compared with the effects in patients with no renal disease. Of 132,372 patients included in the analysis, 3587 (2.7%) had non-end-stage chronic kidney disease and 901 (0.7%) required renal-replacement therapy at the time of inclusion. As compared with patients who did not have renal disease, patients with non-end-stage chronic kidney disease had an increased risk of stroke or systemic thromboembolism (hazard ratio, 1.49; 95% confidence interval [CI], 1.38 to 1.59; P<0.001), as did those requiring renal-replacement therapy (hazard ratio, 1.83; 95% CI, 1.57 to 2.14; P<0.001); this risk was significantly decreased for both groups of patients with warfarin but not with aspirin. The risk of bleeding was also increased among patients who had non-end-stage chronic kidney disease or required renal-replacement therapy and was further increased with warfarin, aspirin, or both. Chronic kidney disease was associated with an increased risk of stroke or systemic thromboembolism and bleeding among patients with atrial fibrillation. Warfarin treatment was associated with a decreased risk of stroke or systemic thromboembolism among patients with chronic kidney disease, whereas warfarin and aspirin were associated with an increased risk of bleeding. (Funded by the Lundbeck Foundation.).

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Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey.

David Kaufman, Judith P. Kelly, Lynn Rosenberg … (2002)

Data on the range of prescription and over-the-counter drug use in the United States are not available. To provide recent population-based information on use of all medications, including prescription and over-the-counter drugs, vitamins and minerals, and herbal preparations/natural supplements in the United States. Ongoing telephone survey of a random sample of the noninstitutionalized US population in the 48 continental states and the District of Columbia; data analyzed here were collected from February 1998 through December 1999. Use of medications, by type, during the preceding week, compared by demographic characteristics. Among 2590 participants aged at least 18 years, 81% used at least 1 medication in the preceding week; 50% took at least 1 prescription drug; and 7% took 5 or more. The highest overall prevalence of medication use was among women aged at least 65 years, of whom 12% took at least 10 medications and 23% took at least 5 prescription drugs. Herbals/supplements were taken by 14% of the population. Among prescription drug users, 16% also took an herbal/supplement; the rate of concurrent use was highest for fluoxetine users, at 22%. Reasons for drug use varied widely, with hypertension and headache mentioned most often (9% for each). Vitamins/minerals were frequently used for nonspecific reasons such as "health" (35%); herbals/supplements were also most commonly used for "health" (16%). In any given week, most US adults take at least 1 medication, and many take multiple agents. The substantial overlap between use of prescription medications and herbals/supplements raises concern about unintended interactions. Documentation of usage patterns can provide a basis for improving the safety of medication use.

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Prevalence, attributes, and outcomes of fitness and frailty in community-dwelling older adults: report from the Canadian study of health and aging.

D Hogan, Réjean Hébert, Kenneth Rockwood … (2004)

Frailty and fitness are important attributes of older persons, but population samples of their prevalence, attributes, and outcomes are limited. The authors report data from the community-dwelling sample (n = 9008) of the Canadian Study of Health and Aging, a representative, 5-year prospective cohort study. Fitness and frailty were determined by self-reported exercise and function level and testing of cognition. Among the community-dwelling elderly population, 171 per 1000 were very fit and 12 per 1000 were very frail. Frailty increased with age, so that by age 85 years and older, 44 per 1000 were very frail. The risk for adverse health outcomes increased markedly with frailty: Compared with older adults who exercise, those who were moderately or severely frail had a relative risk for institutionalization of 8.6 (95% confidence interval, 4.9 to 15.2) and for death of 7.3 (95% confidence interval, 4.7 to 11.4). These risks persist after adjustments for age, sex, comorbid conditions, and poor self-rated health. At all ages, men reported higher levels of exercise and less frailty compared with women. Decreased fitness and increased frailty were also associated with poor self-ratings of health (42% in the most frail vs 7% in the most fit), more comorbid illnesses (6 vs 3), and more social isolation (34% vs 29%). Fitness and frailty form a continuum and predict survival. Exercise influences survival, even in old age. Relative fitness and frailty can be determined quickly in a clinical setting, are potentially useful markers of the risk for adverse health outcomes, and add value to traditional medical assessments that focus on diagnoses.

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Author and article information

Journal

Journal ID (nlm-ta): Korean Circ J

Journal ID (iso-abbrev): Korean Circ J

Journal ID (publisher-id): KCJ

Title: Korean Circulation Journal

Publisher: The Korean Society of Cardiology

ISSN (Print): 1738-5520

ISSN (Electronic): 1738-5555

Publication date Collection: October 2018

Publication date (Electronic): 11 September 2018

Volume: 48

Issue: 10

Pages: 873-889

Affiliations

[1 ]Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.

[2 ]Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.

Author notes

Correspondence to Peter A. Noseworthy, MD. Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA. noseworthy.peter@ 123456mayo.edu

Author information

Avi Sabbag https://orcid.org/0000-0003-4295-6679

Peter A. Noseworthy https://orcid.org/0000-0002-4308-0456

Article

DOI: 10.4070/kcj.2018.0261

PMC ID: 6158453

PubMed ID: 30238705

SO-VID: 4992680c-a822-4489-bad1-366fb54c2535

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This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 09 August 2018

Date revision received : 14 August 2018

Date accepted : 30 August 2018

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Anticoagulation for Stroke Prevention in Older Adults with Atrial Fibrillation and Comorbidity: Current Evidence and Treatment Challenges

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Stroke MRI

Most cited references 72

Stroke and bleeding in atrial fibrillation with chronic kidney disease.

Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey.

Prevalence, attributes, and outcomes of fitness and frailty in community-dwelling older adults: report from the Canadian study of health and aging.

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