https://doi.org/10.4081/ecj.2020.8838
Anticoagulation therapy in older patients at risk for syncopal and not-syncopal fall and/or frailty. An AcEMC-GIMSI multidisciplinary consensus document
Published: 16 March 2020
Abstract Views: 1405
PDF: 521
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
Authors
In aged patients, the most frequent indications for anticoagulation are atrial fibrillation (AF) and venous thromboembolism for stroke and systemic embolism prevention. Despite systemic anticoagulation recommended by current guidelines for patients over 65 years, in clinical practice up to 50 % of elderly patients do not receive maintenance anticoagulation therapy. This is particularly evident in frail subjects at risk of syncopal and not-syncopal fall, fearing intracranial bleeding following a fall. As the risk of bleeding associated with falls is still debated, the boards of the Academy of Emergency Medicine and Care (AcEMC) and the Italian Multidisciplinary Working Group on Syncope (GIMSI), in order to write a consensus document, submitted to a panel of experts eight statement which could represent as many controversial topics for anticoagulant prescription in patients over 75 years. The Delphi method was used to obtain consensus between 15 physicians from different medical specialties; some of them were expert in syncope management and worked in a Syncope Unit. All had experience in prescribing oral anticoagulation. A questionnaire was sent on the appropriateness of oral anticoagulation in eight clinical situations where the risk of fall is present (frailty, cognitive impairment, previous falls, absence of caregiver, chronic renal impairment, nonvalvular AF with HAS-BLED score ≥3 or CHA2DS2-VASc score ≥3). All experts completed the questionnaire within three rounds and the consensus was reached on many but not all statements, leaving room for debate on some clinical situations. The consensus document gives useful advice for elderly patients’ management, who need oral anticoagulant therapy but are at risk of syncopal or not-syncopal fall. Nonetheless, there are some unresolved issues where an individual decision should be taken by the physician in agreement with the patient.
Robert-Ebadi H and Righini M. Anticoagulation in the elderly. Pharmaceuticals. 2010; 3: 3543-3569
DOI: https://doi.org/10.3390/ph3123543
Kirchhof P, Benussi S, Kotecha D et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016; 37: 2893–2962
DOI: https://doi.org/10.1093/eurheartj/ehw210
Rich MW. Atrial fibrillation in long term care. J Am Med Dir Assoc. 2012;13:688–691.
DOI: https://doi.org/10.1016/j.jamda.2012.07.009
Geerts, W.H.; Bergqvist, D.; Pineo, G.F.; Heit, J.A.; Samama, C.M.; Lassen, M.R.; Colwell, C.W.
Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Clinical Practice Guidelines (8th Edition). Chest. 2008, 133, 381S-453S.
DOI: https://doi.org/10.1378/chest.08-0656
Tritschler T, Aujesky D. Venous thromboembolism in the elderly: A narrative review. Thromb Res. 2017 Jul;155:140-147
DOI: https://doi.org/10.1016/j.thromres.2017.05.015
Indication for antithrombotic therapy for atrial fibrillation: reconciling the guidelines with clinical practice. Eur Heart J Suppl.7, Suppl. C, May 2005, C28–C33 pp.
DOI: https://doi.org/10.1093/eurheartj/sui017
Colonna P, Andreotti F, Ageno W, Pengo V, Marchionni N. Clinical conundrums in antithrombotic therapy management: A Delphi Consensus panel. Int J Card. 2017 Dec 15;249:249-256
DOI: https://doi.org/10.1016/j.ijcard.2017.09.159
Jones J, Hunter D. Consensus methods for medical and health services research. BMJ. 1995;311:376–80.
DOI: https://doi.org/10.1136/bmj.311.7001.376
Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012 Aug;125(8):773-8
DOI: https://doi.org/10.1016/j.amjmed.2012.01.033
Steffel J, Giugliano RP, Braunwald E et al. Edoxaban versus Warfarin in atrial fibrillation patients at risk of falling: ENGAGE AF-TIMI 48 Analysis. J Am Coll Cardiol. 2016 Sep 13; 68(11):1169-1178.
DOI: https://doi.org/10.1016/j.jacc.2016.06.034
McCrory DC, Matchar DB, Samsa G, Sanders LL, Pritchett EL. Physician attitudes about anticoagulation for nonvalvular atrial fibrillation in the elderly. Arch Intern Med 1995; 155:277–281.
DOI: https://doi.org/10.1001/archinte.1995.00430030071008
Pugh D, Pugh J, Mead GE. Attitudes of physicians regarding anticoagulation for atrial fibrillation: a systematic review. Age Ageing 2011; 40:675–683.
DOI: https://doi.org/10.1093/ageing/afr097
Sellers MB, Newby LK. Atrial fibrillation, anticoagulation, fall risk, and outcomes in elderly patients. Am Heart J 2011; 161:241–246.
DOI: https://doi.org/10.1016/j.ahj.2010.11.002
Bahri O, Roca F, Lechani T, et al. Underuse of oral anticoagulation for individuals with atrial fibrillation in a nursing home setting in France: comparisons of resident characteristics and physician attitude. J Am Geriatr Soc. 2015; 63:71–76.
DOI: https://doi.org/10.1111/jgs.13200
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 Apr 12;159(7):677-85
DOI: https://doi.org/10.1001/archinte.159.7.677
Fumagalli S, Tatjana S. Torben P, Bjerregaard. Frailty syndrome: an emerging clinical problem in the everyday management of clinical arrhythmias. The results of the European Heart Rhythm Association survey. Europace. 2017; 19: 1896–1902
DOI: https://doi.org/10.1093/europace/eux288
Martinez BK, Sood NA, Bunz TJ, Coleman CI. Effectiveness and safety of Apixaban, Dabigatran, and Rivaroxaban versus Warfarin in frail patients with nonvalvular Atrial Fibrillation. J Am Heart Assoc. 2018;7 (8):e008643. Published 2018 Apr 13.
DOI: https://doi.org/10.1161/JAHA.118.008643
Lefebvre MC, St-Onge M, Glazer-Cavanagh M, Bell L, Kha Nguyen JN, Viet-Quoc Nguyen P, Tannenbaum C.The Effect of bleeding risk and frailty status on anticoagulation patterns in octogenarians with atrial fibrillation: The FRAIL-AF Study. Canadian Journal of Cardiology 32 (2016) 169e176.
DOI: https://doi.org/10.1016/j.cjca.2015.05.012
Veronese N, Ceredac E, Stubbs B et al: Risk of cardiovascular disease morbidity and mortality in frail and pre-frail older adults: Results from a meta-analysis and exploratory meta-regression analysis. Ageing Research Reviews 35 (2017) 63–73)
Patti G, Pecen L, Lucerna M et al: Outcomes of anticoagulated patients with atrial fibrillation treated with or without antiplatelet therapy - A pooled analysis from the PREFER in AF and PREFER in AF PROLONGATON registries. Int J Cardiol. 2018: 270:160-166)
DOI: https://doi.org/10.1016/j.ijcard.2018.06.098
Rao MP, Vinereanu D, Wojdyla DM et al.: Clinical outcomes and history of fall in patients with atrial fibrillation treated with oral anticoagulation: Insights from the ARISTOTLE Trial. Am J Med. 2018;131:269-275.e2
DOI: https://doi.org/10.1016/j.amjmed.2017.10.036
Hagerty T, Rich MW. Fall risk and anticoagulation for atrial fibrillation in the elderly: A delicate balance. Cleve Clin J Med. 2017 Jan; 84(1):35-40.
DOI: https://doi.org/10.3949/ccjm.84a.16016
Mant J, Hobbs FD, Fletcher K, et al; BAFTA investigators; Midland Research Practices Network (MidReC). Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomized controlled trial. Lancet 2007; 370:493–503.
DOI: https://doi.org/10.1016/S0140-6736(07)61233-1
Lip GYH, Clementy N, Pericar Lt, Banerjee A, Fauchier L. Stroke and major bleeding risk in elderly patients aged ≥75 years with atrial fibrillation. The Loire Valley atrial fibrillation project. Stroke. 2015;46:143-150.
DOI: https://doi.org/10.1161/STROKEAHA.114.007199
Chatterjee S, Sardar P, Biondi-Zoccai G, Kumbhani DJ. New oral anticoagulants and the risk of intracranial hemorrhage: traditional and Bayesian meta-analysis and mixed treatment comparison of randomized trials of new oral anticoagulants in atrial fibrillation. JAMA Neurology 2013;70:1486–1490.
DOI: https://doi.org/10.1001/jamaneurol.2013.4021
Sardar P, Chatterjee S, Chaudhari S, Lip GY. New oral anticoagulants in elderly adults: evidence from a meta-analysis of randomized trials. J Am Geriatr Soc 2014; 62:857–864.
DOI: https://doi.org/10.1111/jgs.12799
Chao TF, Liu CJ, Lin YJ, et al. Oral Anticoagulation in very elderly patients with atrial fibrillation: A nationwide cohort study. Circulation. 2018 Jul 3;138(1):37-47
DOI: https://doi.org/10.1161/CIRCULATIONAHA.117.031658
Patti G, Cavallari I, Hanon O, De Caterina R. The safety and efficacy of non-vitamin K antagonist oral anticoagulants in atrial fibrillation in the elderly. Int J Cardiol. 2018; 265: 118–124
DOI: https://doi.org/10.1016/j.ijcard.2018.02.066
Spinola MB, Riccardi A, Minuto P, Campodonico P, Motta G, Malerba M, Guiddo G, Lerza R Hemorrhagic risk and intracranial complications in patients with minor head injury (MHI) taking different oral anticoagulants. Am J Emerg Med. 2019 Sep;37(9):1677-1680.
DOI: https://doi.org/10.1016/j.ajem.2018.12.003
Lavan AH, Gallagher P1, Parsons C, O'Mahony D. STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation. Age Ageing. 2017 Jul 1;46(4):600-607
DOI: https://doi.org/10.1093/ageing/afx005
Fohtung RB, Novak E, Rich MW. Effect of new oral anticoagulants on prescribing practices for atrial fibrillation in older adults. J Am Geriatr Soc. 2017 Nov;65(11):2405-2412.
DOI: https://doi.org/10.1111/jgs.15058
How to Cite
Casagranda, I., Ungar, A., Prevaldi, C., Abete, P., Biagioni, S., Del Rosso, A., Diamanti, M., Fanciulli, A., Fumagalli, S., Furlan, R., Lerza, R., Locatelli, C., Maggi, R., Mussi, C., Numeroso, F., Rabajoli, F., Testa, S., Tomaino, M., & Brignole, M. (2020). Anticoagulation therapy in older patients at risk for syncopal and not-syncopal fall and/or frailty. An AcEMC-GIMSI multidisciplinary consensus document. Emergency Care Journal, 16(1). https://doi.org/10.4081/ecj.2020.8838
PAGEPress has chosen to apply the Creative Commons Attribution NonCommercial 4.0 International License (CC BY-NC 4.0) to all manuscripts to be published.
