Use of direct oral anticoagulants for stroke prevention in elderly patients with nonvalvular atrial fibrillation

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Atrial fibrillation (AF) is a common arrhythmia (Go et al., 2001) and its prevalence increases with age (Chugh et al., 2014). As the proportion of elderly individuals increases over the next decade, rates of AF are expected to increase (Go et al., 2001). AF is a known risk factor for stroke (January et al., 2014b) and risk of stroke increases with age (Rothwell et al., 2005; van Walraven et al., 2009). The American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) guidelines recommend oral anticoagulation for patients with AF and a CHA2DS2‐VASc score of 2 or greater: congestive heart failure/left ventricular dysfunction, hypertension, age ≥75 (2 points), diabetes, stroke (2 points), vascular disease, age 65–74, and sex (female) (January et al., 2014a). A recent consensus document recommends oral anticoagulants for AF if the CHA2DS2‐VASc score is 1 or greater (Ruff et al., 2016). Use of oral anticoagulants—traditionally the vitamin K antagonist warfarin—can be challenging in the elderly for numerous reasons. The objective of this review is to explore these challenges, discuss the data suggesting that direct oral anticoagulants (DOACs) may provide alternative options in this patient population, and explore the evolving role of anticoagulant clinics in this new era of DOAC use.

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