Use of Anticoagulation in Elderly Patients with Atrial Fibrillation Who Are at Risk for Falls

Candice L Garwood, PharmD BCPS; Tia L Corbett, PharmD

Disclosures

The Annals of Pharmacotherapy. 2008;42(4):523-532. 

In This Article

Guideline Recommendations for Anticoagulation in Atrial Fibrillation

The ACCP guidelines recommend use of aspirin 325 mg for patients with AF who are considered to have a low stroke risk. Either aspirin 325 mg daily or warfarin with an international normalized ratio (INR) goal of 2.0-3.0 is recommended for individuals with intermediate stroke risk. Only warfarin, with a target INR goal of 2.0-3.0, is recommended for high-risk patients. High-risk factors include age greater than 75 years, prior ischemic stroke, transient ischemic attack, systemic embolism, moderately or severely impaired left ventricular function, congestive heart failure, history of hypertension, or diabetes. Patients at intermediate stroke risk are between 65 and 75 years old, with no other risk factors. Low-risk patients are defined as those younger than 65 years of age with no other risk factors.[2]

The ACC/AHA/ESC guidelines are similar to the ACCP guidelines in their recommendations for treatment of low-risk AF. ACC/AHA/ESC recommends aspirin 81-325 mg daily for patients less than 65 years of age with no other risk factors. However, these guidelines set stricter criteria for high-risk patients with AF and risk of stroke and expand the criteria for intermediate risk in comparison with the ACCP guidelines. ACC/AHA/ESC recommends warfarin for AF, with a target INR of 2.0-3.0 for patients with any high-risk factor or with more than one moderate-risk factor. High-risk factors include prior stroke, transient ischemic attack, systemic embolism, or rheumatic mitral stenosis. Moderate-risk factors are age 75 years or older, hypertension, congestive heart failure, impaired left ventricular function, or diabetes. Aspirin or warfarin can be considered for prophylaxis in a patient with only one moderate-risk factor for stroke. Additionally, a patient who is aged 65-74 years, female, and/or who has coronary artery disease may be treated with either aspirin 81-325 mg daily or warfarin. Therefore, following ACC/AHA/ESC guidelines may result in a greater number of patients who are recommended to receive aspirin instead of warfarin for intermediate-risk AF. The ACC/AHA/ESC guidelines state that patients younger than 60 years of age who have no other risk factors should not receive warfarin. According to these guidelines, no treatment may be an option, as the long-term effectiveness of aspirin is not established.[5]

Uncertainty over the optimal treatment for elderly patients with AF still exists. ACCP recommends that a patient aged 75 years or older who has no other risk factors receive warfarin. Alternatively, ACC/AHA/ESC recommends aspirin as an appropriate option in such a patient. ACC/AHA/ESC guidelines suggest that patients aged 75 years and older who are considered to be at high risk for bleeding may be treated with a lower INR goal of 1.6-2.5.[5] This recommendation is based upon expert consensus derived from a predictive model, without support of clinical trial data.[14] The ACCP guidelines are written from an evidence-based approach, whereas the ACC/AHA/ESC guidelines are consensus based.[2,5,15] Variance in the guidelines is reflected in current practice.

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