Tackling anti-coagulation under-prescription in the elderly

Atrial fibrillation (AF) is an age-associated common arrhythmia, with a prevalence increasing from <0.1% to 10% in individuals aged ≤55 and ≥80 years respectively [1]. Currently, the over-80s population is growing fastest and projected to increase from 137 to 425 million over the next 30 years [2]; a change that will result in a further rise in AF prevalence. The focus therefore needs to shift towards enforcing measures that will alleviate the disease burden which will undoubtedly follow. In this regard, a key focus in AF management is stroke prevention with oral anti-coagulation (OAC) [3]. For the elderly patient, the risk of stroke is amplified by the combination of age and AF; both which are independent risk factors for stroke. Having AF results in a 5-fold increase in the risk, which at the age of 80-84 years is about 23% [4]. Disappointingly, a significant proportion of the elderly remain non-anticoagulated. Under-appreciation of stroke risks and over-estimated bleeding risks go handin-hand at influencing this. Elderly patients are also disadvantaged by a lack of uniformity in physicians’ perceptions and (until recently) guidelines, owing to limited data from randomised controlled trials specific to the elderly. Also, OAC therapy is partly dependent on the experience and views of the physician. The presence of age-related factors such as frailty, polypharmacy and co-morbidities like dementia confound matters by impugning patients’ abilities to comply with or safely tolerate the perceived ‘high-risk treatment’. Not only this but because these factors are associated with falls, there is much fear about bleeding complications, which prevents physicians from initiating treatment. As a result, many are prescribed agents like aspirin as a middle ground, which have been proven ineffective at preventing AF-related strokes [5]. Time and again, questions are raised about the overall benefit of OAC in the elderly given concerns over bleeding. With the largest observational study of this cohort, Chao et al. [6] addresses this by comparing the risk of ischaemic stroke to the risk of intracranial haemorrhage (ICH) in Taiwanese patients ≥90 years, to determine the net clinical benefit (NCB) of OAC. Two cohorts were studied; one from the pre-NOAC era (1996-2011) and the other from the NOAC era (20122015). For the former group, these risks were compared a mean follow-up of 2.06±2.15 years, a significantly Editorial