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BJC Arrhythmia Watch

Clinical Articles, Featured

Expert suggests there is ‘no absolute age cut-off for anticoagulation’

Given the challenges of antithrombotic treatment in the elderly, the European Society of Cardiology (ESC) Working Group on Thrombosis task group has recently published an expert position paper on this important topic.1

Antiplatelet, anticoagulant, and fibrinolytic drugs can prevent, postpone, or attenuate the severity of thrombotic events – such as stroke, and myocardial infarction (MI), and retard cardiovascular and all-cause death, particularly in elderly patients, but at the cost of increased bleeding. The critical conundrum is whether, in the older patient, the benefits outweigh the bleeding risks, in the view of the paper’s authors.

To avoid older people being denied antithrombotic drugs because of unjustified concerns, or conversely being inappropriately over-treated, this patient oriented consensus document has focused on age-specific risks and benefits of antithrombotic drugs tested in phase III trials and provides recommendations

Professor Felicita Andreotti (Catholic University, Rome, Italy)

Professor Felicita Andreotti (Catholic University, Rome, Italy)

BJC Arrhythmia Watch interviewed the lead author, of the paper Professor Felicita Andreotti, Institute of Cardiology, Catholic University, Rome, Italy, who summarises many of the key recommendations.

Is this the first such paper which focuses on the elderly?

“This is the first paper to focus on antithrombotic therapy in the elderly in a systematic and comprehensive way. The paper reports age-stratified thrombotic and bleeding event rates extracted from the major randomised trials of oral or parenteral antithrombotic drugs for both arterial and venous diseases. For the first time, a table of recommendations is provided.

There are sections on non-vitamin K antagonist oral anticoagulants, fibrinolysis, how to prevent and manage bleeding, and discussion of clinical cases. The whole document is supported by a European and partly North American panel of experienced clinician-scientists”.

Integrating age in to thrombosis and bleeding risk appears to be challenging. Is there now a case for all patients over a certain age (>65 years) to have a CHA2DS2-VASC and HAS-BLED assessment prior to commencing anticoagulation?

“We believe the scores should be used regardless of age whenever antithrombotic therapy is being considered. These two scores – assessing thromboembolic and bleeding risk in a semi-quantitative way – were developed for patients with atrial fibrillation but can be applied to other patient groups and to antithrombotic agents other than anticoagulants. Both scores include age as an essential component. Other items of the scores, such as hypertension, concomitant intake of drugs that affect haemostasis, alcohol abuse, and suboptimal INR, can potentially be modified to reduce the risk of adverse events.”

Is such assessment feasible/suitable for the primary care (i.e. GP) setting?

“The simplicity and broad applicability of these scores make them feasible and suitable for all care settings including primary care”.

Are there other risk engines for the elderly in the pipeline or in current use?

“Most risk calculators for thrombosis, bleeding or early death consider age. In the setting of acute coronary syndromes, for instance, the GRACE 2 and TIMI scores, that estimate the probability of short-term death, both include age, while the CRUSADE score, that predicts rates of in-hospital major bleeds, integrates age indirectly through the Cockcroft-Gault formula and through the presence or absence of diabetes, anaemia, vascular disease and heart failure, which are all more prevalent in the elderly”.

Is there any absolute age cut-off beyond which anticoagulation should not be introduced or is it more a component of biological versus chronological age?

“There is no absolute age cut-off for anticoagulation. In fact, none of the recent anticoagulation trials in atrial fibrillation excluded patients because of advanced age. In older patients, however, lower doses of dabigatran (in Europe), apixaban (if combined with either poor renal function or low body weight) and enoxaparin are recommended.

For those aged 75 or above we also recommend caution with glycoprotein IIb/IIIa inhibitors and with fibrinolysis, avoidance of a clopidogrel bolus with fibrinolysis, and half dose tenecteplase with the pharmacoinvasive strategy.

The patient’s history, particularly of prior stroke/TIA and especially of intracranial haemorrhage, may represent an absolute contraindication for strong antiplatelet agents, for fibrinolysis, or for prolonged dual or triple antithrombotic therapy.

Renal function needs to be assessed to dose-reduce or avoid drugs that are mainly renally cleared, such as low molecular weight heparins, fondaparinux, dabigatran, bivalirudin, eptifibatide and tirofiban.

The greatest challenge is that age and other predictors of thrombosis overlap with predictors of bleeding, pointing at an overall vascular vulnerability of the older individual.

As the growing global population ages, there is a special need for randomised evidence to guide and refine antithrombotic therapy in the elderly”.


1. Andreotti F, Rocca B, Husted S, et al. Antithrombotic therapy in the elderly: expert position paper of the European Society of Cardiology Working Group on Thrombosis. Euro Heart J 2015;36:3238–49.

Published on: January 14, 2016

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