Stroke prevention in atrial fibrillation: physicians’ attitudes to anticoagulation in older people

Anticoagulant use in older persons at risk for falls: therapeutic dilemmas-a clinical review

PURPOSE

The aim of this clinical narrative review was to summarise the existing knowledge on the use of anticoagulants and potential adverse events in older people at risk of falls with a history of atrial fibrillation or venous thromboembolism. The review also offers practical steps prescribers can take when (de-)prescribing anticoagulants to maximise safety.

METHODS

Literature searches were conducted using PubMed, Embase and Scopus. Additional articles were identified by searching reference lists.

RESULTS

Anticoagulants are often underused in older people due to concerns about the risk of falls and intracranial haemorrhage. However, evidence suggests that the absolute risk is low and outweighed by the reduction in stroke risk. DOACs are now recommended first line for most patients due to their favourable safety profile. Off-label dose reduction of DOACs is not recommended due to reduced efficacy with limited reduction in bleeding risk. Medication review and falls prevention strategies should be implemented before prescribing anticoagulation. Deprescribing should be considered in severe frailty, limited life expectancy and increased bleeding risk (e.g., cerebral microbleeds).

CONCLUSION

When considering whether to (de-)prescribe anticoagulants, it is important to consider the risks associated with stopping therapy in addition to potential adverse events. Shared decision-making with the patient and their carers is crucial as patient and prescriber views often differ.

Prescribing of anticoagulation for atrial fibrillation in primary care

Atrial fibrillation (AF) is common in primary care patients. Many patients who could benefit from anticoagulation do not receive it. The objective of this study was to describe anticoagulation prescribing by primary care physicians. We conducted an observational study in the Cleveland Clinic Health System among patients with AF and ≥ 1 primary care appointment between 2015 and 2018 and their physicians. We estimated differences in the odds of an eligible patient receiving anticoagulation versus not and a DOAC versus warfarin using two mixed effects logistic regression models, adjusted for patient sociodemographic factors, history of falls or dementia, and CHA2DS2-VASc and HAS-BLED scores. We categorized physicians into prescribing tertiles, based on their adjusted prescribing rate, which we included as predictors in the models. Among 5253 patients, 47% received anticoagulation. Of those, 56% received a DOAC. CHA2DS2-VASc and HAS-BLED scores were not associated with anticoagulation prescription. Black race was negatively associated with receiving anticoagulation overall (aOR:0.71; 95%CI:0.56-0.89) and with prescription for a DOAC (aOR:0.65; 95%CI:0.45-0.93). Among 195 physicians, the anticoagulation prescribing rate ranged from 27% to 57% and DOAC rates ranged from 34% to 69%. Physician prescribing tertile was associated with odds of a patient receiving anticoagulation overall (aOR:1.51; 95%CI: 1.13-2.01 for the highest versus lowest tertile), but not DOAC prescriptions. When prescribing anticoagulation, physicians appear not to consider risk of stroke or bleeding but patient race is an important determinant. Seeing a physician with a high anticoagulation prescribing rate was strongly associated with a patient receiving it, suggesting a lack of individualization.

Utility of HAS-BLED and CHA2DS2-VASc Scores Among Patients With Atrial Fibrillation and Imaging Evidence of Cerebral Amyloid Angiopathy

OBJECTIVE

To determine the utility of the HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol concomitantly) and CHA₂DS₂-VASc (Congestive heart failure, Hypertension, Age, Diabetes, previous Stroke/transient ischemic attack-VAScular disease) scores among patients on anticoagulation (AC) therapy for atrial fibrillation (AF) who have evidence of cerebral amyloid angiopathy (CAA).

PATIENTS AND METHODS

Patients older than 55 years with a diagnosis of AF who had a nontraumatic intracerebral hemorrhage (ICH) while on AC therapy between 1995 and 2016 were identified using the Rochester Epidemiology Project Database. Medical records were reviewed, including imaging of the brain, to identify baseline characteristics, AC use, and outcomes.

RESULTS

A total of 65 patients were identified (mean age, 81.3 years); 35 (53.8%) had evidence of possible/probable CAA. Mean HAS-BLED score in the CAA group was significantly lower (2.1) than that of the non-CAA group (2.9; P<.001). Mortality after ICH, adjusted for HAS-BLED scores, was not significantly different among patients with and without CAA. Sixteen patients restarted on AC therapy after ICH; CHA₂DS₂-VASc scores were no different between this group and those who were not restarted. Among patients with CAA, the overall rate of ICH recurrence was 8.6% over 93.5 person-years of follow-up. Among patients with CAA, the rate of ICH recurrence was 3.2 per 100 patient-years, higher than their HAS-BLED scores would predict (1.9 bleeds/100 patient-years).

CONCLUSION

HAS-BLED scores were lower in patients who had evidence of CAA compared with those without, suggesting underestimation of ICH risk in patients with CAA. CHA₂DS₂-VASc scores did not affect resumption of AC therapy. ICH recurrence was higher in patients with CAA than their HAS-BLED scores predicted. Current risk assessment scoring systems do not accurately account for CAA in patients with AF on AC.

Cardiovascular aspects of geriatric medicines in traditional Persian medicine; a review of phytochemistry and pharmacology

BACKGROUND

Geriatrics are a group of patients over 65 years and with multiple comorbidities and different functional impairments. Apart from decline in body mass, presence of exhaustion and general fatigue, an aged person may also suffer from various disorders. Approximately, around 30% of geriatric subjects have significant cardiovascular ailments. Apart from the intensive management of cardiovascular aspects in elderly, monitoring of the complementary cardiac medicine in those people should be received more attention.

PURPOSE

There are many management lines for a cardio-geriatric condition in Traditional Persian Medicine (TPM). Accordingly, this paper aimed to deal with those medicaments as well as evidence-based clinical aspects and phytochemistry.

METHODS

By searching through main pharmaceutical manuscripts of Persian medicine during 10th-18th centuries (A.D.), concurrently, natural medicines for geriatrics and remedies for cardiovascular ailments were derived. On the other side, related phytochemical and pharmacological aspects of those remedies were highlighted.

RESULTS

In all, 38 cardiovascular and 34 geriatric medicaments were found in those manuscripts. Antihyperlipidemic and cholesterol lowering activities of those medicines were the most reported activities in current medicine. However, other pharmacological reports were related to hypotensive, coagulant, cardio-protective and cardiotonic activities. In regard of the chemical composition, medicaments were mainly of polyphenols and flavonoids and also most of the employed extracts and fractions were yielded from polar or semi-polar solvents.

CONCLUSION

With reference to these findings, flavonoid-rich medicaments from Persian medicine may be selected as considerable herbs for geriatrics with cardiovascular ailments.

Atrial fibrillation and stroke prevention

There is overwhelming evidence from randomized trials and systematic reviews to indicate the benefit of thromboprophylaxis in patients with atrial fibrillation. In moderate- to high-risk subjects, oral anticoagulation with warfarin reduces stroke by two-thirds, while aspirin reduces stroke by 22%. The latter result is similar to that seen for stroke reduction with antiplatelet therapy in vascular disease. Numerous studies have shown that less than half the patients eligible for warfarin therapy actually receive it and under- or overanticoagulation is common. This leads to many missed opportunities in optimizing stroke prevention in atrial fibrillation. The limitations of existing oral anticoagulants have resulted in the development of many new drugs. The aim of this review is to provide a brief overview of thromboprophylaxis in atrial fibrillation, and the opportunities for improvement in the provision made for thromboprophylaxis.

Factors associated with undertreatment of atrial fibrillation in geriatric outpatients with Alzheimer disease

BACKGROUND

According to international recommendations [from the American College of Cardiology/American Heart Association/European Society of Cardiology] and those of the Haute Autorité de Santé (HAS) in France, treatment with a vitamin K antagonist is recommended in patients with atrial fibrillation (AF) in the presence of a high thromboembolic risk factor [history of stroke, transient ischemic attack, systemic embolism, or valvular heart disease, or presence of a mechanical heart valve prosthesis] or at least two moderate risk factors (age ≥75 years, hypertension, congestive heart failure, or diabetes). In patients with a major contraindication, the vitamin K antagonist can be replaced by an antiplatelet agent (APA). These recommendations are not systematically observed in patients with Alzheimer disease (AD). The aim of our study was to determine the factors associated with undertreatment of AF in geriatric outpatients with AD.

METHODS

Use of oral anticoagulants or APAs was studied in 66 patients with AF who were included in the French Network on Alzheimer Disease (REAL.FR) cohort, consisting of 686 outpatients living at home, supported by an informal caregiver, and suffering from Alzheimer-type dementia, with a Mini Mental Status Examination (MMSE) score between 10 and 26. First, demographic characteristics (age, sex, body mass index [BMI], living arrangements, educational level), medical conditions (comorbidity, number of medications), disability (activities of daily living [ADL], instrumental activities of daily living [IADL]), risk of falls (one-leg balance test), cognitive status (according to MMSE, Alzheimer's Disease Assessment Scale-Cognitive Subscale [ADAS-Cog], and Clinical Dementia Rating [CDR] scores), risk factors for stroke (hypertension, history of stroke, congestive heart failure, diabetes, or age ≥75 years) and potential contraindications to oral anticoagulants (OACs) or APAs (polypharmacy, risk of falls, renal failure, gastrointestinal diseases) of patients receiving OACs were compared with those of patients receiving APAs and those of patients receiving no treatment for AF. Then the same characteristics were compared between patients receiving no treatment for AF and those receiving OACs or APAs.

RESULTS

Only 56 % (n = 37) of patients with AF were receiving OACs or APAs at the baseline visit, of whom 18 (49 %) were receiving OACs and 19 (51 %) were receiving APAs. Bivariate analysis showed that patients receiving OACs or APAs were significantly more likely to have a history of cardiovascular disease (p = 0.005)-in particular, hypertension (p = 0.037)-less likely to be living alone and unaided (p = 0.038), and less likely to be taking nonsteroidal anti-inflammatory drugs [NSAIDs] (p = 0.001).

CONCLUSION

Despite the national and international recommendations, nearly half of AD patients with AF do not receive OACs or APAs. A history of cardiovascular disease-in particular, hypertension-improves access to treatment, but use of NSAIDs and living alone without home care seem to be the main factors associated with non-prescription of OACs or APAs.

GP's adherence to guidelines for cardiovascular disease among elderly: a quality development study

Background. Evidence-based guidelines should in most cases be followed also in the treatment of elderly. Older people are often suboptimally treated with the recommended drugs. Objectives. To describe how well general practitioners adhere to current guidelines in the treatment of elderly with cardiovascular disease and evaluate local education as a tool for improvement. Method. Data was collected from the medical records of patients aged ≥65, who visited a primary health care center in Sweden 2006 and had one or more of the following diagnoses: hypertension, ischemic heart disease, heart failure, chronic atrial fibrillation, or prior stroke. Local education was organized and included feed-back to the patient's doctor and discussion about regional guidelines. Repeated measurements were performed in 2008. Results and Conclusion. The adherence to guidelines was low. Approximately one-third of the patients with hypertension reached target blood pressure, stroke patients more often. More patients with heart failure were treated with angiotensin converting enzyme inhibitor than in other European countries, but still only 60%. Half of the patients with chronic atrial fibrillation were treated with Warfarin, although more than two-thirds had a CHADS₂ score indicating the need. Educational efforts appeared to increase the adherence and hence should be encouraged.

Preventative Measures of Stroke in Patients With Atrial Fibrillation

Atrial fibrillation (AF) is the commonest sustained cardiac arrhythmia and is associated with increased morbidity and mortality due to stroke and thrombo-embolism. In patients with AF, strokes are usually more severe, resulting in longer hospital stays, worse disability and considerable healthcare costs. The prevention of stroke therefore is crucial in the management of AF. Stroke risk stratification tools can be used to determine patients at higher risk of stroke, and if no contraindications are present oral anticoagulation (OAC) therapy can be initiated. Despite the strong evidence for the benefit of OAC in stroke prevention in patients with AF, the use of thromboprophylaxis remains inadequate. The key measures to prevent stroke in patients with AF include: adequate stroke risk assessment and thrombo-prophylaxis; prompt initiation of OAC and avoidance of interruptions; earlier detection of AF; and education to overcome the under-usage of OAC in elderly patients.

Attitudes of physicians regarding anticoagulation for atrial fibrillation: a systematic review

BACKGROUND

the efficacy of warfarin for prevention of stroke in patients with atrial fibrillation (AF) is well established, but many people with AF who would benefit from warfarin are not receiving it. This systematic review aims to determine physicians' attitudes to the prescription of warfarin for AF, and identify reasons for its underuse.

METHODS

an electronic search of MEDLINE (1950-present), EMBASE (1980-present), CINAHL (1994-present), PsycINFO (1987-present) and Web of Knowledge (1970-present) was performed in November 2010 to identify all studies which addressed, via survey, physicians' attitudes regarding anticoagulation for patients with AF.

RESULTS

a total of 1,375 citations were identified. Of these citations, 44 full text studies were obtained for scrutinisation; 14 of these studies were rejected leaving 30 studies which were included in the review. All included studies were cross-sectional surveys and addressed physicians' opinions of anticoagulation in AF as a primary or secondary aim. Increasing age, increased bleeding risk, previous bleeds, falls risk, co-morbidities and ability to comply with treatment influenced whether physicians would prescribe anticoagulation for AF.

CONCLUSION

physicians are reticent to recommend warfarin for elderly patients in AF, despite evidence of increased benefit in these patients compared with younger patients. Risk of falls and previous bleeding were also shown to be disproportionate barriers to warfarin prescription. Further studies are required to determine how best to overcome these perceived barriers to appropriate anticoagulation.

Quality of management of oral anticoagulation as assessed by time in therapeutic INR range in elderly and younger patients with low mean years of formal education: a prospective cohort study

BACKGROUND

despite the overwhelming evidence of its effectiveness, oral anticoagulation continues to be underused in the elderly, presumably due to physicians' misconceptions when estimating bleeding risk and ability to comply with treatment.

OBJECTIVE

to investigate the quality of anticoagulation control among deprived elderly and younger patients.

DESIGN

prospective observational study.

SETTING

a public anticoagulation clinic in a developing country.

SUBJECTS

all adult patients on intended long-term (>90 days) oral anticoagulation. We studied 171 patients (79 elderly and 92 non-elderly) with a mean follow-up of 273 ± 84.9 days.

METHODS

the main outcome measure was the quality of anticoagulation management as measured by the time in therapeutic (TTR) international normalised ratio (INR) range. Elderly patients (≥60 years) were compared with younger patients with respect to the educational level and co-morbidities.

RESULTS

the mean number of years of formal education was 4.37 ± 3.2 years. The mean TTR was 62.50 ± 17.9% in non-elderly and 62.10 ± 16.6% in elderly (P = 0.862) subjects, despite the higher prevalence of co-morbidities in the latter group: heart failure (46.3 versus 28.6%, P = 0.042), diabetes mellitus (22.8 versus 8.7%, P = 0.011), renal failure (estimated glomerular filtration rate <50 ml/min: 38.0 versus 7.1%, P < 0.001) and polypharmacy (84.8 versus 58.7%, P < 0.001). Fifty elderly and 84 non-elderly subjects require little or no assistance in taking medications. Among them, the elderly had lower educational levels (3.42 ± 2.5 versus 5.55 ± 3.4 years of formal education, P < 0.001) and higher rates of cognitive impairment (34.0 versus 13.1%, P = 0.004), but a similar mean TTR (62.46 ± 16.1 versus 63.02 ± 17.8%, P = 0.856). The oldest (≥75 years) patients did as well as those aged ≤50 years (mean TTR: 62.54 ± 16.0 versus 62.23 ± 16.4%, respectively, P = 0.98).

CONCLUSIONS

good-quality management of oral anticoagulation is achievable in deprived populations attending an anticoagulation clinic. Elderly patients may experience similar quality of anticoagulation despite having higher levels of co-morbidities and polypharmacy. These results add evidence to the safety of such therapeutic interventions in the elderly.

Impact on decisions to start or continue medicines of providing information to patients about possible benefits and/or harms: a systematic review and meta-analysis

BACKGROUND

The impact of providing information about medicines to patients on decisions about starting or continuing them is unknown.

PURPOSE

To estimate the impact on decisions to start or continue medicines, of providing information to patients about possible benefits and/or harms.

DATA SOURCES

Electronic searches from 1980 to October 2010; reference and citation searches of included studies.

STUDY SELECTION

Two investigators assessed studies' eligibility against inclusion criteria: randomized or pseudorandomized trials; participants older than 16 years and deciding for themselves; one group received information about possible benefits and/or harms of a potentially beneficial medicine, compared with another who did not; d) a measure of decision about starting or continuing a medicine.

DATA EXTRACTION

One investigator extracted all data, checked by a second.

DATA SYNTHESIS

Eight studies were included, covering a range of medicines. There was no consistent impact of interventions on decisions about whether to start or continue medicines (pooled odds ratio 1.08; 95% confidence interval [CI], 0.69-1.70; P = 0.74). Among those who received more information, knowledge was increased (pooled mean difference 8.47; 95% CI 2.17-14.77; P = 0.008), and decisional conflict was reduced (pooled mean difference -0.15; 95% CI -0.24 to -0.06; P = .001).

LIMITATIONS

A small number of studies across different clinical contexts, of uncertain heterogeneity, were included.

CONCLUSIONS

Providing information to patients about possible benefits and/or harms has no consistent effect on the number who decide to start or continue medicines, although it increases patients' knowledge and reduces their decisional conflict.

Reasons for undertreatment with oral anticoagulants in frail geriatric outpatients with atrial fibrillation: a prospective, descriptive study

OBJECTIVES

The main aims of the study were to explore whether oral anticoagulation (OAC) for atrial fibrillation (AF) in geriatric outpatients is prescribed in accordance with international (American College of Cardiology/American Heart Association/European Society of Cardiology [ACC/AHA/ESC]) and Dutch national guidelines for the general practitioner (GP) and to identify whether age and selected co-morbid conditions are associated with undertreatment. As a secondary objective, we wanted to establish how many patients discontinue OAC because of major bleeding.

METHODS

In 2004, at the first visit of all patients to the geriatric day clinic of the Slotervaart Hospital in Amsterdam, the Netherlands, demographic data, Mini-Mental State Examination score, medical history, Charlson Comorbidity Index score, and data on medication use and changes were documented. The presence of AF was established by assessment of medical history information obtained by the GP, the history taken from patients and their caregivers, and the results of clinical evaluation, including ECG findings. Associations between the use of OAC, demographic data and co-morbid conditions registered in the Dutch NHG (Nederlands Huisartsen Genootschap [Dutch College of General Practitioners]) standard for GPs as risk factors for stroke or contraindications to the use of OAC were analysed. The reasons for discontinuing OAC were assessed after 4 years by requesting the information from the anticoagulation services or the GP.

RESULTS

At the time of the initial visit, 17.5% of the 807 outpatients had chronic AF (n = 135) or were known to have paroxysmal AF (n = 6). The mean age of the 141 patients in this cohort was 84.3 years (SD 6.2 years). Co-morbid conditions increasing the risk of stroke were present in 129 patients (91.5%). Contraindications to the use of OAC were observed in 118 patients (83.7%). Of the 116 patients with AF in their history before their visit, 57.8% were being treated with OAC at the time of their visit. After comprehensive geriatric assessment, 73 (51.8%) of the 141 patients with chronic or paroxysmal AF were continued on OAC. Of the 141 patients with chronic or paroxysmal AF, 110 (78.0%) had both extra stroke risk factors and contraindications to the use of OAC. Only increasing age was significantly and independently associated with not being prescribed anticoagulants (p < 0.001). At the 4-year follow-up, OAC had been discontinued in 5.5% of patients because of major bleeding; three patients (4.1%) taking OAC had died as a result of major bleeding, and one other patient had discontinued treatment because of a major, non-lethal bleeding episode.

CONCLUSION

Applying the NHG standard for appropriate prescription, and disregarding age as a risk factor or contraindication, in this population, 14 of 141 patients (9.9%) were inappropriately prescribed OAC, salicylates or no prophylaxis. Since only patient age was associated with not prescribing OAC in this study, higher age still seems to be considered the most important contraindication to anticoagulation therapy. Implementation of better models for stratifying bleeding risk in the frail elderly is needed. After 4 years, the cumulative rate of bleeding causing discontinuation of anticoagulation therapy in this usual-care study of frail older patients was not alarmingly higher than in other usual-care studies.

Medical treatment of patients with atrial fibrillation aged over 80 years in daily clinical practice: influence of age and CHADS(2) score

The purpose of the present study was to evaluate clinical data and medical treatment of very elderly patients with atrial fibrillation (AF) who are under-represented in the majority of AF studies. In this retrospective study, patients over 80 years with AF admitted to the cardiology ward during a 1-year period were investigated with respect to the type of AF, clinical characteristics, and rate or rhythm control strategy. In addition, the influence of age and CHADS(2) score on antithrombotic therapy was examined. A total of 169 consecutive patients (mean+/-S.D. age: 84.7+/-4.0 years) were included in this study. Rate control medication was administered in 79% of the patients at discharge. Oral anticoagulation (OAC) was prescribed in only 27.5% of the patients with a CHADS(2) score of > or =2 for reasons of poor compliance or unfavorable clinical conditions. Moreover, patients older than 85 years received OAC less frequently than those aged between 80 and 84 years (7% vs. 36%, p<0.001). Our results indicate a real need for educational programs aimed at instructing all staff involved with this group of patients, so that the necessary pre-conditions for a maximum OAC therapy can be achieved in these very elderly AF patients.

Potentially Preventable Strokes in High-Risk Patients With Atrial Fibrillation Who Are Not Adequately Anticoagulated

Background and Purpose— Warfarin is the most effective stroke prevention medication for high-risk individuals with atrial fibrillation, yet it is often underused. This study examined the magnitude of this problem in a large contemporary, prospective stroke registry.

Methods— We analyzed data from the Registry of the Canadian Stroke Network, a prospective database of consecutive patients with stroke admitted to 12 designated stroke centers in Ontario (2003 to 2007). We included patients admitted with an acute ischemic stroke who (1) had a known history of atrial fibrillation; (2) were classified as high risk for systemic emboli according to published guidelines; and (3) had no known contraindications to anticoagulation. Primary end points were the use of prestroke antithrombotic medications and admission international normalized ratio.

Results— Among patients admitted with a first ischemic stroke who had known atrial fibrillation (n=597), strokes were disabling in 60% and fatal in 20%. Preadmission medications were warfarin (40%), antiplatelet therapy (30%), and no antithrombotics (29%). Of those taking warfarin, three fourths had a subtherapeutic international normalized ratio (<2.0) at the time of stroke admission. Overall, only 10% of patients with acute stroke with known atrial fibrillation were therapeutically anticoagulated (international normalized ratio ≥2.0) at admission. In stroke patients with a history of atrial fibrillation and a previous transient ischemic attack or ischemic stroke (n=323), only 18% were taking warfarin with therapeutic international normalized ratio at the time of admission for stroke, 39% were taking warfarin with subtherapeutic international normalized ratio, and 15% were on no antithrombotic therapy.

Conclusions— In high-risk patients with atrial fibrillation admitted with a stroke, and who were candidates for anticoagulation, most were either not taking warfarin or were subtherapeutic at the time of ischemic stroke. Many were on no antithrombotic therapy. These findings should encourage greater efforts to prescribe and monitor appropriate antithrombotic therapy to prevent stroke in individuals with atrial fibrillation.

Use of anticoagulation in elderly patients with atrial fibrillation who are at risk for falls

OBJECTIVE

To evaluate data addressing use of anticoagulation in elderly patients with atrial fibrillation (AF), in particular those at risk of falls.

DATA SOURCES

Primary literature was identified through PubMed MEDLINE (1966-December 2007) and EMBASE (1980-December 2007) using the search terms anticoagulation, warfarin, aspirin, elderly, falls, older persons, atrial fibrillation, bleeding, education, stroke, and use. Additional references were obtained through review of references from articles obtained.

STUDY SELECTION AND DATA EXTRACTION

Clinical studies evaluating warfarin and aspirin efficacy in AF, as well as studies evaluating anticoagulation and falls, elderly patients, and bleeding were considered for inclusion. Selection emphasis was placed on randomized studies of AF and those evaluating anticoagulation and falls.

DATA SYNTHESIS

Uncertainties over the optimal treatment for elderly patients with AF still exist. Variance in the guidelines is reflected in current practice, as some discrepancies are present. Warfarin is underprescribed in elderly patients, with only about 50% of eligible patients receiving therapy. Falls are most often cited as the reason for not using anticoagulants in an elderly patient. Three risk-benefit analyses have been performed, and all found that despite risks associated with warfarin, its benefits outweigh its risks even in patients who fall. Warfarin should be used rather than aspirin or no therapy in elderly patients at risk of falls. Anticoagulation education has been shown to reduce the risk of bleeding in the elderly and should be a vital part of warfarin management.

CONCLUSIONS

The risk of falls alone should not automatically disqualify a person from being treated with warfarin. While falls should not dictate anticoagulant choice, assessment and management of fall risk should be an important part of anticoagulation management. Efforts should be made to minimize fall risk.

Anticoagulation in women with non-valvular atrial fibrillation in the stroke prevention using an oral thrombin inhibitor (SPORTIF) trials

AIMS

The risk of stroke is greater among women with atrial fibrillation (AF) than men. Warfarin protects against stroke, but treatment-related bleeding occurs more often in women than in men.

METHODS AND RESULTS

SPORTIF III (open label, n=3410) and V (double-blind, n=3922) included 2257 women with AF and one or more stroke risk factors randomized to warfarin [target international normalized ratio (INR) 2.0-3.0] or ximelagatran (36 mg twice daily). Primary outcomes were all stroke (ischaemic/haemorrhagic) and systemic embolic event. Women were older, on average, than men, 73.4+/-8.0 vs. 69.8+/-9.0 years (P<0.0001). More women were >75-years old and women had more risk factors than men had (P<0.0001). The INR on warfarin (mean 2.5+/-0.7) was within target range for 67% of follow-up regardless of gender. Women more often developed primary events [2.08%/year, 95% confidence interval (CI) 1.60-2.56%/year vs. 1.44%/year, 95% CI 1.18-1.71%/year in men; P=0.016). Major bleeding rates were similar (P=0.766) but women experienced more overall (major/minor) bleeding (P<0.001). Warfarin was associated with more overall bleeding in both genders and more major bleeding in women than in men (P=0.001).

CONCLUSION

When compared with men with AF, women in these studies were older and had more stroke risk factors. Women were more prone to anticoagulant-related bleeding; the higher rate of thrombo-embolism among women was related to more frequent interruption of anticoagulant therapy.

[Intracerebral hemorrhage related to anticoagulant therapy]

Intracerebral hemorrhage (ICH) is the most serious complication of oral anticoagulant therapy (OAT). The growing use of OAT has resulted in an increase of fatal ICH. The mortality rate is about 65%, and most of the surviving patients remain disabled. While improvements in the treatment of spontaneous ICH have recently been described, there are no internationally accepted guidelines for managing patients with OAT-ICH. Therefore, identifying effective treatments is essential for improving clinical outcome. This article reviews the epidemiology of OAT-ICH, its pathophysiology, and current treatment options and discusses open questions with particular respect to more recent pharmacological therapies.

Cardiovascular Emergencies in the Elderly

Already the major cause of mortality in the United States, cardio-vascular emergencies will become increasingly prevalent in the future as the geriatric population doubles. This article discusses five cardiovascular emergencies: acute coronary syndrome, congestive heart failure, dysrythmias, aortic dissection, and ruptured abdominal aortic aneurysm. The discussion focuses on the differences in presentation, management, and outcomes that characterize each disease amongst the elderly. As a rule, the elderly have significantly worse outcomes than younger patients.

Controversies in atrial fibrillation

Atrial fibrillation is the most common sustained cardiac arrhythmia, and contributes greatly to cardiovascular morbidity and mortality. Many aspects of the management of atrial fibrillation remain controversial. We address nine specific controversies in atrial fibrillation management, briefly focusing on the relations between mechanisms and therapy, the roles of rhythm and rate control, the definition of optimum rate control, the need for early cardioversion to prevent remodelling, the comparison of electrical with pharmacological cardioversion, the selection of patients for long-term oral anticoagulation, the roles of novel long-term anticoagulation approaches and ablation therapy, and the potential usefulness of upstream therapy targeting substrate development. The background of every controversy is reviewed and our opinions expressed. Here, we hope to inform physicians about the most important controversies in this specialty and stimulate investigators to address unresolved issues.

How good is anticoagulation control in non-valvar atrial fibrillation? Observations on the elderly, ethnicity, patient perceptions, and understanding of AF thromboprophylaxis

There continues to be a wide variation of opinion among UK consultants regarding the best treatment strategies for ensuring effective thromboprophylaxis of atrial fibrillation.

Prevention of Cardiovascular Events in Elderly People

BACKGROUND AND OBJECTIVE

Cardiovascular disease has been identified as the leading cause of morbidity and mortality in developed countries. Given the increase in life expectancy and the development of cardiovascular preventive measures, it has become increasingly important to detect and prevent cardiovascular diseases in the elderly. We reviewed the scientific literature concerning cardiovascular prevention to assess the importance of cardiovascular preventive measures in old (> or =65 years of age) individuals.

METHODS

We undertook a systematic search for references relating to prevention of cardiovascular disease in the elderly, mainly ischaemic stroke, coronary artery disease and heart failure, on the MEDLINE database 1962-2005. For cardiovascular prevention by drugs or surgery, emphasis was placed on randomised controlled trials, review articles and meta-analyses. For cardiovascular prevention by lifestyle modification, major cohort studies were also considered.

RESULTS

Stroke, coronary heart disease and heart failure were found to be the main targets for cardiovascular prevention in published studies. Antihypertensive treatment has proven its efficacy in primary prevention of fatal or nonfatal stroke in hypertensive and high-risk patients >60 years of age, particularly through treatment of systolic hypertension. Systolic blood pressure reduction is equally important in the secondary prevention of stroke. Similarly, in nonvalvular atrial fibrillation, an adjusted dose of warfarin with a target International Normalized Ratio (INR) of between 2 to 3 prevents ischaemic stroke in elderly patients with an acceptable haemorrhagic risk but is still under prescribed. Antiplatelet agents are indicated in elderly patients with nonembolic strokes. Few large-scale studies have investigated the effect of HMG-CoA reductase inhibitors (statins) on stroke prevention in old individuals. To date, the largest trials suggest a beneficial effect for stroke prevention with use of statins in high-risk elderly subjects < or =82 years of age. Carotid endarterectomy is indicated in carotid artery stenosis >70% and outcomes are even better in elderly than in younger patients. However, medical treatment is still the first-line treatment in asymptomatic elderly patients with <70% stenosis. In ischaemic heart disease, different trials in elderly individuals have shown that use of statins, antithrombotic agents, beta-adrenoceptor antagonists and ACE inhibitors plays an important role either in primary or in secondary cardiovascular prevention. Hormone replacement therapy has been used to treat climacteric symptoms and postmenopausal osteoporosis and was thought to confer a cardiovascular protection. However, controlled trials in elderly individuals changed this false belief when it was found that there was no benefit and even a harmful cardiovascular effect during the first year of treatment. Smoking cessation, regular physical activity and healthy diet are, as in younger individuals, appropriate and effective measures for preventing cardiovascular events in the elderly. Finally, antihypertensive treatment and influenza vaccination are useful for heart failure prevention in elderly individuals.

CONCLUSIONS

Cardiovascular prevention should be more widely implemented in the elderly, including individuals aged > or =75 years, and this might contribute to improved healthy status and quality of life in this growing population.