Antiplatelet therapy is not a safer alternative to oral anticoagulants, even in older hospital-discharged patients with atrial fibrillation

Although oral anticoagulant therapy (OAT) is recommended for patients with atrial fibrillation (AF), it is widely underused among older patients, who are frequently prescribed antiplatelet therapy (APT) instead. We assessed mortality and incidence of ischemic and hemorrhagic events according to prescription of OAT or APT in older medical in-patients with AF discharged from hospital. Stroke and bleeding risk were evaluated using the CHA₂DS₂-VASC (Congestive heart failure/ left ventricular dysfunction, Hypertension, Aged ≥75 years, Diabetes Mellitus, Stroke/transient ischemic attack/systemic embolism, Vascular Disease, Aged 65-74 years, Sex Category) and HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol concomitantly) scores. Comorbidity, cognitive status and functional autonomy were assessed using standardized scales. Association of OAT and APT with overall mortality, ischemic stroke and bleeding events was evaluated through multivariate analysis and propensity score matching. During a mean follow-up period of 11 months 384 of the 962 patients discharged (mean age 82.9±6.6 years, 59.1% female) died (39.9%), 66 had an ischemic stroke and 49 experienced a major bleeding event. Compared with APT, OAT was associated with reduced overall mortality after multivariate analysis [odds ratio (OR) 0.62, confidence interval (CI): 0.46-0.83] and after propensity score matched analysis (OR 0.65, CI: 0.52-0.82, P=0.0004), with a not significant reduced incidence of total and fatal ischemic stroke, and without increase in total, intracranial, major and fatal bleedings. In a sample of older AF patients with poor health status, OAT was associated with reduced mortality, without evidence of a significant increase in major or fatal bleedings.