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• W3119685132 abstract "Stroke prevention is the cornerstone in the management of patients with atrial fibrillation (AF). Oral anticoagulation (OAC) has been the main strategy to reduce the risk of thromboembolism in most AF patients.1Alkhouli M. Noseworthy P.A. Rihal C.S. Holmes Jr., D.R. Stroke Prevention in nonvalvular atrial fibrillation: a stakeholder perspective.J Am Coll Cardiol. 2018; 71: 2790-2801Crossref PubMed Scopus (25) Google Scholar However, its effective use is hampered by several challenges, including the attended bleeding risk, noncompliance, and cost.2Holmes Jr., D.R. Alkhouli M. Reddy V. Left atrial appendage occlusion for the unmet clinical needs of stroke prevention in nonvalvular atrial fibrillation.Mayo Clin Proc. 2019; 94: 864-874Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Elderly patients are further disadvantaged with additional factors that may limit the use of OAC, such as frailty, polypharmacy, and functional dependence.3Lindley R.I. Stroke Prevention in the very elderly.Stroke. 2018; 49: 796-802Crossref PubMed Scopus (13) Google Scholar In addition, there are limited data to guide stroke prevention decisions in these patients; octogenarians are typically excluded from clinical trials, and observational data specific to their age group are sparse. Nonetheless, AF continues to be a major and increasing cause of stroke and disability in this population. In a nationwide US survey, more than 40% of patients aged 85 years and older admitted with ischemic stroke in 2014 had AF.4Alkhouli M. Alqahtani F. Aljohani S. Alvi M. Holmes D.R. Burden of atrial fibrillation–associated ischemic stroke in the United States.JACC Clin Electrophysiol. 2018; 4: 618-625Crossref PubMed Scopus (33) Google Scholar With the rising prevalence of AF in the ever-growing elderly populations worldwide, efforts to bridge this knowledge gap are welcomed. In this issue of the Journal, Cheng et al5Cheng W.C.C. Lin Y. Chang S. et al.Non-vitamin K antagonist oral anticoagulants in elderly (>85) patients with newly-diagnosed atrial fibrillation—changing clinical practice and outcomes for stroke prevention in a nationwide cohort study.Mayo Clin Proc. 2021; 96: 52-65Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar identified 33,539 patients 85 years of age and older who were diagnosed with new-onset AF between 2009 and 2015 in a National Health Insurance database in Taiwan to address 2 questions: (1) Did the advent of direct oral anticoagulants (DOACs) lead to an increased use of OAC in the very elderly? and (2) Was that associated with a reduction in stroke, bleeding, and mortality in this population? The authors also assessed predictors of OAC underuse before and after the introduction of DOACs. The main findings of the study were the following. First, the use of OAC increased significantly during the study period (from 9.5% in 2019 to 34.3% in 2015), driven mainly by the increasing prescription of DOACs. Second, the 1-year risk of ischemic stroke and death after AF diagnosis decreased over time, but major bleeding and intracranial hemorrhage rates remained mostly stable. Third, anemia, lung disease, and history of bleeding remained associated with lower OAC use before and after the introduction of DOACs, but renal insufficiency (which is highly prevalent in the elderly) became a negative predictor of use in the era of DOACs. The authors are to be congratulated for bringing this issue of stroke prevention in the elderly back to the spotlight. The findings of this study are intriguing and serve to emphasize the potential key role for DOACs in the management of AF in the very elderly. However, further scrutiny is warranted to ensure proper interpretation of these data and their practical implications and to discuss the remaining open questions.1.Was the increasing use of DOACs in this study truly associated with a reduction in ischemic stroke rates? The use of administrative data sets in cardiovascular research, although growing and well validated, requires mindfulness of some specific issues with such databases.6AlHajji M. Alqahtani F. Alkhouli M. Contemporary trends in the utilization of administrative databases in cardiovascular research.Mayo Clin Proc. 2019; 94: 1120-1121Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar In this study, the authors used 2 sets of billing codes to identify stroke and bleeding events within 1 year after AF diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] for patients diagnosed in 2009-2014, and International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] for those diagnosed in 2015). The transition from ICD-9 to ICD-10 in 2015 corresponded to substantial declines in ischemic stroke rates from 4.39% in the 2014 cohort to 2.75% in the 2015 cohort. Unfortunately, it is not possible to discern whether this is a true effect of DOACs or a mere coding issue, but the magnitude of this abrupt change supports the latter. Whereas this limitation does not affect the reported utilization rates of OAC or mortality outcomes, it attenuates the authors’ argument for a true impact of adoption of DOACs on 1-year stroke rates. Similar concerns apply to the reported rates of major bleeding and intracranial hemorrhage.2.Is there a true persistent gap with prophylactic OAC use among the elderly in the DOAC era? Two-thirds of patients aged 85 years and older were still not receiving OAC in 2015, which was 3.5 years, 3 years, and 1.5 years after the introduction of dabigatran, rivaroxaban, and apixaban, respectively, in Taiwan. Is this due to a lag in the adoption of DOACs in some patients, or does it simply reflect the realistic cap of what can be achieved in a population with high prevalence of major comorbidities?7Potpara T.S. Mujovic N. Lip G.Y.H. Challenges in stroke prevention among very elderly patients with atrial fibrillation: discerning facts from prejudices.Europace. 2020; 22: 173-176Crossref PubMed Scopus (4) Google Scholar What would be the reasonable target utilization rate in this population, considering that the use of OAC among AF patients of any age remains around 50% in the United States even in the DOAC era?2Holmes Jr., D.R. Alkhouli M. Reddy V. Left atrial appendage occlusion for the unmet clinical needs of stroke prevention in nonvalvular atrial fibrillation.Mayo Clin Proc. 2019; 94: 864-874Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar3.Is there a role for nonpharmacologic stroke prevention in very elderly AF patients? Granular data on frailty, functional independence, degree of renal insufficiency, type and severity of prior bleeding, and other important factors that may have an impact on the decision to initiate OAC are not available in this study. However, it is clear that many of these patients would probably not be suitable for long-term OAC as suggested by the high prevalence of prior bleeding (∼50% in 2015), anemia, and liver and renal insufficiency. Will the increasingly used left atrial appendage closure devices fill this gap, or does the risk-benefit ratio of invasive procedures in this population still favor a more conservative approach? Would this change with the emergence of novel (and potentially safer) devices and the wider adoption of minimalistic procedural techniques in the future?8Alkhouli M. Chaker Z. Alqahtani F. Raslan S. Raybuck B. Outcomes of routine intracardiac echocardiography to guide left atrial appendage occlusion.JACC Clin Electrophysiol. 2020; 6: 393-400Crossref PubMed Scopus (14) Google Scholar4.Are these data generalizable to the global populations? Baseline characteristics, stroke and bleeding risks, medication preference and compliance, and life expectancy among Asian patients differ from those in patients from other races and ethnicities.9Alkhouli M. Friedman P.A. Ischemic stroke risk in patients with nonvalvular atrial fibrillation: JACC review topic of the week.J Am Coll Cardiol. 2019; 74: 3050-3065Crossref PubMed Scopus (23) Google Scholar Unfortunately, similar data from other countries are not available at present. Hence, caution is warranted in extrapolating the suggested potential benefit of DOACs in this study of Asian patients to other populations.5.Is it time to revisit our stroke prediction methods in patients with nonvalvular AF? The authors offer a rare glimpse into the performance of CHA₂DS₂-VASc in predicting AF-associated stroke in the very elderly. In this study, before the emergence of DOACs, patients had a CHA₂DS₂-VASc score of about 5.3, which corresponds to predicted annual stroke rates between 7.2% and 9.7%. However, the reported 1-year ischemic stroke rates were significantly less (in the range of ∼5%), despite the negligible OAC use (<10% in 2009) in the pre-DOAC era. This begets the question of whether the CHA₂DS₂-VASc overestimates the risk of stroke and whether this is a global issue or one specific to elderly Asian patients.9Alkhouli M. Friedman P.A. Ischemic stroke risk in patients with nonvalvular atrial fibrillation: JACC review topic of the week.J Am Coll Cardiol. 2019; 74: 3050-3065Crossref PubMed Scopus (23) Google Scholar Although almost all of these patients would still be candidates for OAC on the basis of an annual stroke rate of about 5%, the overestimated risk might have an impact on the individual patient’s decision to accept or to decline OAC.10Hijazi M. Aljohani S. Alqahtani F. et al.Perception of the risk of stroke and the risks and benefits of oral anticoagulation for stroke prevention in patients with atrial fibrillation: a cross-sectional study.Mayo Clin Proc. 2019; 94: 1015-1023Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We can all agree that stroke prevention in AF patients is of the utmost importance to all stakeholders involved, but this is a reminder that our reliance on crude risk scores with modest predictive value may need revisiting.9Alkhouli M. Friedman P.A. Ischemic stroke risk in patients with nonvalvular atrial fibrillation: JACC review topic of the week.J Am Coll Cardiol. 2019; 74: 3050-3065Crossref PubMed Scopus (23) Google Scholar Our nation is aging, and our elderly are disproportionately affected by AF and its sequelae. This study suggests a potential role for DOACs in reducing stroke risk in AF patients 85 years of age and older, but it also highlights the need to devote more efforts to study and to implement optimal stroke prevention strategies in this growing population. Non–Vitamin K Antagonist Oral Anticoagulants in Elderly (≥85 years) Patients With Newly Diagnosed Atrial Fibrillation: Changing Clinical Practice and Outcomes for Stroke Prevention in a Nationwide Cohort StudyMayo Clinic ProceedingsVol. 96Issue 1PreviewTo investigate the influences of non–vitamin K antagonist oral anticoagulants (NOACs) on rates of initiations of oral anticoagulants (OACs) and outcomes among elderly patients with atrial fibrillation (AF). Full-Text PDF" @default.
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• W3119685132 title "Stroke Prevention in Very Elderly Patients With Nonvalvular Atrial Fibrillation Revisited" @default.
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