Efficacy and safety of direct oral anticoagulants in older adults with atrial fibrillation: a prospective single-centre cohort study

IntroductionDirect oral anticoagulants (DOACs) are underused in the elderly, regardless the evidence in their favour in this population.MethodsWe prospectively enrolled anticoagulant-naive patients aged & GE; 75 years who started treatment with DOACs for atrial fibrillation (AF) and stratified them in older adults (aged 75-84 years) and extremely older adults (& GE; 85 years). Thrombotic and hemorrhagic events were evaluated for 12 months follow-up.ResultsWe enrolled 518 consecutive patients. They were mostly aged 75-84 years (299 patients; 57.7%) vs. & GE; 85 years (219 patients; 42.3%). Extremely older adults showed higher incidence of all the endpoints (systemic cardioembolism [HR 3.25 (95% CI 1.71-6.18)], major bleeding [HR 2.75 (95% CI 1.77-4.27)], and clinically relevant non-major bleeding [HR 2.13 (95% CI 1.17-3.92)]) vs. older adults during the first year after starting anticoagulation. In patients aged & GE; 85 years, no difference in the aforementioned endpoints was found between those receiving on-label vs. off-label DOACs. In the extremely older adults, chronic kidney disease, polypharmacy, use of antipsychotics, and DOAC discontinuation correlated with higher rates of thrombotic events, whereas a history of bleeding, Charlson Index & GE; 6, use of reduced DOAC dose, absence of a caregiver, use of non-steroidal anti-inflammatory drugs (NSAIDs), and HAS-BLED score & GE; 3 were associated with major bleedings.ConclusionsNaive patients aged & GE; 85 who started a DOAC for AF are at higher risk of thrombotic and bleeding events compared to those aged 75-84 years in the first year of therapy. History of bleeding, HAS-BLED score & GE; 3 and use of NSAIDs are associated with higher rates of major bleeding.