Atrial Fibrillation and Stroke Prevention in Aging Patients

The most common arrhythmia in older adults is atrial fibrillation, with an estimated prevalence of ≈9% in adults aged ≥80 years and a concomitant increased burden of developing stroke. Additionally, over the past decade, both the incidence and prevalence of atrial fibrillation has markedly increased1 and, with it, the total number of patients potentially requiring long-term oral anticoagulation therapy for the prevention of stroke and systemic embolism. In 2009, the estimated number of atrial fibrillation diagnoses in the United States was 2 643 000, with equal distribution between men and women and 82% at ages ≥65 years, with that number increasing 10% between 1999 to 2005.2 The magnitude of the problem is exemplified by the fact that the risk of stroke in patients with atrial fibrillation increases with age and accounts for ≈45% of embolic strokes, approximately 100 000 annually in the United States.3Article see p 138The advent of the novel oral anticoagulants has strikingly shifted the goalposts in the field of stroke prevention. Large randomized trials of 4 agents involving 71 683 participants4 have demonstrated that these drugs are at least noninferior to warfarin for the prevention of stroke and systemic embolism and, in the case of apixiban and higher doses of dabigatran, the trials demonstrated superiority over warfarin. In addition, these agents have demonstrated a consistent and striking impact on reducing intracerebral hemorrhage and major bleeding. Moreover, a recent meta-analysis demonstrated an overall reduction in mortality of ≈10%.4A major issue in these studies is the increased bleeding and stroke rates in select populations. Among patients with atrial fibrillation treated with anticoagulation, the risk was found to be higher among Asians, blacks, and the elderly.5 Complicating the treatment for atrial fibrillation in the aging population is a higher risk of …