Oral Anticoagulation in the Elderly: New Oral Anticoagulants-Innovative Solution for an Old Problem?

Direct oral anticoagulants emerge as the most innovative and promising drug toward preventing and treating cardiovascular disease, raising great interest among the scientific community. Numerous studies and meta-analysis generated much data clarifying clinicians' doubts; however, uncertainties remain regarding their use in particular groups such as patients with prosthetic valves, in valvular atrial fibrillation (defined as atrial fibrillation related to mitral rheumatic heart disease or prosthetic heart valves), among the elderly, in paraneoplastic thromboembolism, in pulmonary embolism with hemodynamic compromise, and scarcity of specific antidotes. This review article intends to condense the vast scientific production addressing new oral anticoagulants by focusing on their advantages and disadvantages when used on the elderly.

Thrombolysis in Patients Aged over 80 Years Is Equally Effective and Safe

BACKGROUND: Despite stroke's high prevalence in the elderly, intravenous thrombolysis is licensed in Europe only for patients younger than 80 years old. We aimed to compare the functional outcomes and complication rates in patients older versus younger than 80 years old treated with intravenous thrombolysis. METHODS: A retrospective observational study of patients who received intravenous thrombolysis in a stroke unit between January 1, 2009, and June 30, 2012, was conducted. Variables were compared between 2 subgroups (≤80 and >80 years). RESULTS: Overall, 512 patients underwent intravenous thrombolysis, of which 13.1% were over 80 years. The mean age was 65.4 years in the younger subgroup and 82.9 years in the older subgroup. Prior independence rates did not differ between the subgroups. Prevalence of atrial fibrillation and cardioembolic stroke was higher in the older subgroup (P = .004 and .026). Only 3% of the elderly with atrial fibrillation were taking oral anticoagulants. Symptoms-to-needle time was lower in the older subgroup (P = .048). Stroke severity was higher in patients over 80 years (P = .026). There was significant improvement in the National Institutes of Health Stroke Scale score 7 days after intravenous thrombolysis (P < .001) in both subgroups. The proportion of patients with 3 months' favorable outcome and independence, hemorrhagic transformation, and mortality rates were similar in both subgroups. CONCLUSIONS: Elderly patients' benefits and outcomes from intravenous thrombolysis treatment were identical to the younger subgroup without excess hemorrhagic transformation or mortality. These results favor the use of intravenous thrombolysis in patients over 80 years.

Rivaroxabananddabigatraninpatientsundergoing catheter ablation of atrial fibrillation

Aims: The recent availability of the novel oral anticoagulants (NOACs) may have led to a change in the anticoagulation regimens of patients referred to catheter ablation of atrial fibrillation (AF). Preliminary data exist concerning dabigatran, but information regarding the safety and efficacy of rivaroxaban in this setting is currently scarce. Methods: and results Of the 556 consecutive eligible patients (age 61.0 ± 9.6; 74.6% men; 61.2% paroxysmal AF) undergoing AF catheter ablation in our centre (October 2012 to September 2013) and enroled in a systematic standardized 30-day follow-up period: 192 patients were under vitamin K antagonists (VKAs), 188 under rivaroxaban, and 176 under dabigatran. Peri-procedural mortality and significant systemic or pulmonary thromboembolism (efficacy outcome), as well as bleeding events (safety outcome) during the 30 days following the ablation were evaluated according to anticoagulation regimen. During a 12-month time interval, the use of the NOACs in this population rose from <10 to 70%. Overall, the rate of events was low with no significant differences regarding: thrombo-embolic events in 1.3% (VKA 2.1%; rivaroxaban 1.1%; dabigatran 0.6%; P = 0.410); major bleeding in 2.3% (VKA 4.2%; rivaroxaban 1.6%; dabigatran 1.1%; P = 0.112), and minor bleeding 1.4% (VKA 2.1%; rivaroxaban 1.6%; dabigatran 0.6%; P = 0.464). No fatal events were observed. Conclusion: The use of the NOAC in patients undergoing catheter ablation of AF has rapidly evolved (seven-fold) over 1 year. These preliminary data suggest that rivaroxaban and dabigatran in the setting of catheter ablation of AF are efficient and safe, compared with the traditional VKA.