More bleeding in vulnerable elderly people who switch to DOAC

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Vulnerable elderly people with atrial fibrillation (AF) in whom the vitamin K antagonist (VKA) is replaced by one of the newer direct-acting oral anticoagulants (DOACs) have significantly more bleeding. This is shown by a Dutch study by Linda Joosten of the UMC Utrecht et al., which was published in Circulation at the end of August and was presented at the conference of the European Society of Cardiology (ESC) in Amsterdam.

Patients with AF and an increased thromboembolic risk receive anticoagulation to prevent thromboembolic complications. This is preferably a DOAC, such as rivaroxaban, because less bleeding is seen with this than with VKAs such as acenocoumarol. The effectiveness is the same. About 30 to 40 percent of all elderly people with AF still use a VKA. In general, patients with AF who are still using a VKA are switched to a DOAC. But whether older and vulnerable (‘frail’) patients, a population not included in previous studies into the safety and effectiveness of DOACs versus VKAs, also benefit from this is unclear.

Switch

The researchers therefore divided 1,330 vulnerable elderly people aged 75 years or older with AF who were already treated with a VKA into two groups. One group continued with the VKA, the other switched to a DOAC. ‘Frailty’ was defined using a validated questionnaire, the Groningen Frailty Indicator (GFI). The choice of the type of DOAC was left to the prescriber. ‘Major’ or clinically relevant ‘non-major’ bleeding and thromboembolic events were recorded over a period of one year.

Stopped prematurely

The mean age was 83 years, the CHA2DS2-VASc score 4. All DOAC classes were represented in the study. The DOAC group consisted of 662 patients, the VKA group of 661. Due to the high number of bleeding events, the study was stopped prematurely. A total of 163 bleeding events occurred, of which 101 (15.3%) in the DOAC group and 62 (9.4%) in the VKA group. No firm conclusion could be drawn about effectiveness due to the small number of thromboembolic events. Of these, 16 (2.4%) occurred in the VKA group versus 13 (2%) in the DOAC group.

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