Anticoagulation Myth Busters

MYTH

Oral anticoagulation should be avoided in frail older adults and/or those an increased risk of a fall

REALITY

“With ageing of the population, there will be an increase in the number of frail patients with AF. Anticoagulation is often not prescribed for such patients because of their perceived falls risk. Both NICE and the ESC guidelines are clear in their recommendation: OAC should not be withheld because a patient is at risk of having a fall.1-3

A Markov decision analytic model has demonstrated that a patient treated with a VKA/warfarin would have to fall 295 times per year in order for the risk of a subdural haematoma (including intracranial haemorrhage) to outweigh the benefit of oral anticoagulation.4 Given that the four landmark NOAC trials have demonstrated a statistically significant reduction in the risk of an intracranial haemorrhage when compared to warfarin, this ‘number needed to fall’ would be even higher with the use of NOACs.5-8

Frailty is described as having reduced physiologic reserve and increased susceptibility to disability and increases with age. Being frail may influence the perception of bleeding risk and the decision to initiate oral anticoagulation in the elderly.

The incidence of frailty and its impact on therapy and outcomes in AF has been investigated the Outcomes Registry for Better Informed Care in AF (ORBIT-AF). Among the 9,749 patients with AF investigated, 6% were also found to be frail (as defined by the American Geriatric Society Criteria). Despite a higher median CHA2DS2VASc risk score (P<0.0001), frail patients were less likely to receive oral anticoagulants compared to non-frail patients (67.5% vs. 76.9%, P<0.0001). Frailty was also associated with increased mortality (P=0.006), however, not with stroke/TIA or major bleeding. The findings of this evaluation indicate no statistically significant interaction between frailty and oral anticoagulant use in determining outcomes of all-cause death, major adverse cardiovascular events or major bleeding.9

While in states of severe frailty with poor physical functioning and limited life expectancy there might be limited benefits to oral anticoagulation, older age, frailty and/or increased risk of falls should not be a reason to withhold oral anticoagulation in patients who are at risk of AF-related stroke according to their CHA2DS2-VASc score.9-11

REFERENCES
  1. NICE CG 180. Atrial fibrillation: management. In: Excellence NIfHaC, editor. NICE: NICE; 2014.
  2. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal. 2016;37(38):2893-962.
  3. Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: executive summary. Europace. 2018.
  4. Man-Son-Hing M, Nichol G, Lau A, Laupacis A. Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med. 1999;159(7):677-85.
  5. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139-51.
  6. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883-91.
  7. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981-92.
  8. Giugliano RP, Ruff CT, Braunwald E, Murphy SA, Wiviott SD, Halperin JL, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2013;369(22):2093-104.
  9. Madhavan M, Holmes DN, Piccini JP, Ansell JE, Fonarow GC, Hylek EM, et al. Association of frailty and cognitive impairment with benefits of oral anticoagulation in patients with atrial fibrillation. American Heart Journal. 2019;211:77-89.
  10. O’Brien EC, Holmes DN, Ansell JE, Allen LA, Hylek E, Kowey PR, et al. Physician practices regarding contraindications to oral anticoagulation in atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry. American Heart Journal. 2014;167(4):601-9 e1.
  11. O’Brien EC, Simon DN, Allen LA, Singer DE, Fonarow GC, Kowey PR, et al. Reasons for warfarin discontinuation in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). American Heart Journal. 2014;168(4):487-94.
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