AF and frail elderly population: a newer evidence for the hard decision

Stroke or bleeding?. This isn’t a rational choice, however this is the bitter truth in many frail elderly patients in whom therapeutic anti-caogulation is indicated for atrial fibrillation.

Frail elderly people represent a uniquely fragile group of AF patients as they are gravely prone to both risks of thrombosis and bleeding. Most frail old patients are above 75 yrs of age, so they are at least getting 2 points in the CHA₂DS₂-VASc score, obliging therapeutic anti-coagulation for them.

 Despite steep growth of NOACs use in most categories of non-valvular AF,  its use  in frail elderly patients is still debatable and in need for more and more focused research effort.

In a recent meta-analysis published earlier in February 2023, conducted on the data gained from 10 cohort studies including more than 188000 participants, positive results in favor of use of NOACs in frail elderly AF patients were fulfilled regarding both efficacy and safety. In comparison to Warfarin, NOACs achieved lower rates of CV strokes, systemic embolism, major bleeding, intra-cranial hemorrhage and cardiovascular death. Additionally, both warfarin and NOACs showed no significant differences in terms with GI bleeding. These data conform with earlier data from ESC guidelines for AF 2020, that recommended giving priority to NOACs use in newly diagnosed AF patients in general and shifting from warfarin to NOACs. 

However, we have a fresh contrary evidence from the  FRAIL-AF trial illustrated at the recent ESC Congress in Amesterdam 2023. The study was conducted in 7 thrombosis centers in Netherlands, on frail patients older that 75 yrs of age, who were divided into two groups, one continued on VKAs and the other switched from warfarin to NOACs. 

The results showed that Switching VKA treatment to a NOAC in frail elderly patients with AF was associated with significantly more bleeding complications compared to continuing VKAs (69% higher bleeding events in switch group). This higher bleeding risk is more significant than the minimally lower risk (about 5%) of thromboembolic events achieved in switch group

Practical application:

• Frail patients are gravely susceptible to both bleeding and thrombosis risks, so cautious and meticulous individualized approaches regarding anti-coagulation should be emblemented. 
• If your elderly frail patients are already achieving target INR (TTR >65%) on warfarin, keep them on warfarin and don’t shift to NOACs.
• Sticking to warfarin with a relatively lower therapeutic target (INR 1.8-2.2) may be a wise choice for anti-cogulation in frail elderly patients.
• In de novo patients, you can initiate NOACs with reduced standard therapeutic doses to fit with their low body weight and relatively lower creatinine clearance (for example apixaban 2.5 mgQ12 or rivaroxaban 15 mg Q24) with periodic follow up of CBC and  kidney function. 

#AF  #NOACs #frail #ESCcongress2023