Should elderly patients with atrial fibrillation (AF) and previous episodes of upper gastrointestinal (GI) tract bleeding be given an anticoagulant to prevent stroke? What about older patients with hypertension who have fallen in the past?
Patients like these are less likely to be given warfarin sodium (Generic Coumadin®, DuPont)—and that’s regrettable, say investigators from Ottawa Health Research Institute, University of Ottawa, Sisters of Charity Ottawa Health Service, and the University of Toronto in Canada. They charge that the possibility of major bleeding has scared clinicians away from prescribing anticoagulants for some older patients who might benefit from them.
The researchers, who reviewed studies performed between the 1960s and 2002, say that some “risk factors” do not truly pose a danger after all. For instance, in the era of routine clinical Helicobacter pylori testing and treatment of patients with peptic ulcer bleeding not induced by nonsteroidal anti-inflammatory drugs (NSAIDs), previous episodes of upper GI bleeding do not seem to increase the risk of anticoagulant-related bleeding.
Similarly, old age and a predisposition to falling, in and of themselves, are not influential factors in bleeding. Even when patients take anticoagulants, the risk of subdural hematoma from falling is so small that patients with an average risk of stroke from AF (5% per year) would have to fall approximately 300 times in a year for the risks of anticoagulant therapy to outweigh its benefits, the researchers say. In addition, for many clinically accepted contraindications, such as alcohol abuse, thrombocytopenia, and non-compliance with monitoring, the evidence is minimal or conflicting.
Old age might confer a slightly higher risk of anticoagulant-related bleeding complications, but the researchers emphasize that, of all age groups, people older than age 65 are also at highest risk of stroke from AF. With multiple studies revealing that older persons with AF are the least likely to receive anticoagulant therapy, it seems that many clinicians are overly concerned about the possible negative effects and tend to under-emphasize the potential benefits of anticoagulants. Thus, the investigators conclude, in selecting patients with AF for anticoagulant therapy, stroke risk is a more important consideration than bleeding risk.