Stroke prevention with oral anticoagulation therapy in patients with atrial fibrillation--focus on the elderly.

Atrial fibrillation (AF) is a major risk factor for stroke and the prevalence increases with age. Oral anticoagulants (OACs) are effective, but underused in elderly patients, primarily because of concerns about bleeding. Clinical study data on the efficacy (stroke/systemic embolism) and safety (bleeding events) of OACs in elderly patients with AF, including studies of vitamin K antagonists and newer OACs, were evaluated to determine whether treatment effects vary in elderly vs. younger patients, and whether OACs provide a net clinical benefit for elderly patients. In general, elderly patients had greater risk of both thromboembolic and bleeding events compared with younger patients. Nevertheless, OACs were associated with significant efficacy, with most studies reporting no difference in the risk of bleeding relative to control treatments. In trials of the newer OACs, no interaction was seen between age and relative treatment effects for apixaban or rivaroxaban compared with warfarin, although the rates of extracranial bleeding events increased in older patients treated with dabigatran. In conclusion, OAC therapy is associated with a positive benefit-risk balance in elderly patients. Irrespective of age, treatment decisions regarding stroke thromboprophylaxis in all patients with AF should be based on consideration of individual potential benefits and risks of treatment and patient preferences.