Conundrums for Atrial Fibrillation Management in Older Adults
Atrial fibrillation (AF) afflicts over 33 million people worldwide, the large majority of them older than 65, and increases embolic stroke risk fourfold to fivefold. This stroke risk can be reduced by two thirds or more with anticoagulation, although this benefit is balanced by an increased risk of bleeding. Guidelines recommend use of the CHA2DS2-VASc risk score to estimate annual stroke risk and inform shared decision making between patients and providers. Although the net clinical benefit of anticoagulation for stroke prophylaxis in AF is well established in patients with CHA2DS2-VASc scores ≤2, anticoagulation remains underutilized, especially in older patients. While older patients are at higher risk for bleeding on anticoagulation, they also derive the most benefit from anticoagulation due to their higher stroke risk. In this review, benefits of warfarin and targeted oral anticoagulants will be discussed, and relative utility of these therapies for stroke prophylaxis will be clarified.
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