Anticoagulant therapy strategy in elderly patients: balancing efficacy and safety

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice and is associated with a high risk of death from stroke and thromboembolic complications, the prevention of which is achieved through anticoagulant therapy. The risk of AF increases with age. Managing elderly patients with AF always presents challenges for clinicians due to the need to constantly balance the risks of thromboembolic complications with the potential for bleeding associated with their prevention. However, most studies have shown that bleeding occurs not because the patient is taking an anticoagulant at the selected therapeutic dose, but because the patient has a bleeding substrate. Furthermore, it is necessary to consider possible age-related changes in the pharmacokinetics and pharmacodynamics of drugs, as well as their dangerous combinations and interactions. Another question that arises for clinicians is the strategy for discontinuing anticoagulant therapy in elderly patients due to upcoming invasive examinations or surgery. The article presents algorithms that provide answers to all the questions posed to clinicians.

1. Schnabel RB, Yin X, Gona P, et al. 50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study. Lancet. 2015 Jul 11;386(9989):154-62. doi: 10.1016/S0140-6736(14)61774-8.

2. Druzhilov MA, Kuznetsova TYu. Atrial fibrillation in the elderly and long-livers: a retrospective analysis of the clinical profile of patients using artificial intelligence. Cardiovascular Therapy and Prevention. 2023;22(7):3606. (In Russ.). doi: 10.15829/1728-8800-2023-3606. EDN DCYTQX.

3. Ardashev AV, Belenkov YuN, Matsiukevich MCh, Snezhitskiy VA. Atrial Fibrillation and Mortality: Prognostic Factors and Direction of Prevention. Kardiologiia. 2021;61(2):91-98. (In Russ.). doi: org/10.18087/cardio.2021.2.n1348.

4. Van Gelder IC, Rienstra M, Bunting KV, et al; ESC Scientific Document Group. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024 Sep 29;45(36):3314-3414. doi: 10.1093/eurheartj/ehae176.

5. Joglar JA, Chung MK, Armbruster AL, et al; Peer Review Committee Members. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024 Jan 2;149(1):e1-e156. doi: 10.1161/CIR.0000000000001193.

6. Pharmacotherapy in the Elderly and Senile / DA Sychev, ON Tkacheva, YuV Kotovskaya, IP Malaya. Moscow: Publishing House "KONGRESSKHIM" LLC, 2024. (In Russ.). ISBN 978-5-6052709-2-8

7. Antithrombotic therapy in scales and algorithms. Third joint clinical guidelines of the National Scientific Society of Inflammation and the Russian Scientific Medical Society of Therapists, approved as clinical national guidelines at the XV National Congress of Therapists in 2020, for general practitioners, cardiologists, neurologists, and specialists of other profiles, clinical guidelines for doctors. Lomakin N.V. et al. Moscow: Re Media Advertising Agency LLC, 2020. (In Russ.). ISBN 978-5-6042468-9-4.

8. Moiseev SV. Which scores should use cardiologist to predict outcomes in patients with nonvalvular atrial fibrillation? Klinicheskaya farmakologiya i terapiya. Clin Pharmacol Ther. 2020; 29(4):5-16 (In Russ.). doi: 10.32756/0869-5490-2020-4-5-16.

9. Druzhilov MA, Druzhilova OYu, Kuznetsova TYu, Gavrilov DV. Anticoagulant therapy for atrial fibrillation and high risk of thromboembolic events in certain Russian regions in 2023. Russian Journal of Cardiology. 2025;30(6):6273. (In Russ.). doi: 10.15829/1560-4071-2025-6273. EDN: WCJDKF.

10. Shlyakhto EV, Villevalde SV, Ezhov AV, et al. Clinical performance of the atrial fibrillation in the Russian population depending on the antithrombotic therapy: findings from the GLORIA-AF registry phase 2. Russian Journal of Cardiology. 2020;25(11):4179. (In Russ.). doi: 10.15829/1560-4071-2020-4179.

11. Revishvili ASh, Sulimоv VA. Atrial fibrillation and flutter. KARDIOLOGIYA: novosti, mneniya, obucheniye. 2020; 10, 4 (31), 2022 (In Russ.).

12. Berns SA, Barbarash OL. How to level the risk of bleeding while taking anticoagulant therapy in patients with atrial fibrillation. Consilium Medicum. 2022;24(1):36–41. (In Russ.). doi: 10.26442/20751753.2022.1.20147.

13. Gao X, Cai X, Yang Y, et al. Diagnostic Accuracy of the HAS-BLED Bleeding Score in VKA- or DOAC-Treated Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis. Front Cardiovasc Med. 2021 Nov 22;8:757087. doi: 10.3389/fcvm.2021.757087.

14. Chao TF, Liu CJ, Lin YJ, et al. Oral Anticoagulation in Very Elderly Patients With Atrial Fibrillation: A Nationwide Cohort Study. Circulation. 2018 Jul 3;138(1):37-47. doi: 10.1161/CIRCULATIONAHA.117.031658.

15. Sychev DA, Cherniaeva MS, Rozhkova MA, Vorobyova AE. Potentially Inappropriate Medications for Use in Older Adults: Beers Criteria (2023 American Geriatrics Society Guidelines). Safety and Risk of Pharmacotherapy. 2024;12(3):253-267. (In Russ.). doi: 10.30895/2312-7821-2024-420.

16. Grymonprez M, Steurbaut S, De Backer TL, et al. Effectiveness and Safety of Oral Anticoagulants in Older Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis. Front Pharmacol. 2020 Sep 9; 11:583311. doi: 10.3389/fphar.2020.583311.

17. Lip GYH, Keshishian AV, Kang AL, et al. Oral anticoagulants for nonvalvular atrial fibrillation in frail elderly patients: insights from the ARISTOPHANES study. J Intern Med. 2021 Jan;289(1):42-52. doi: 10.1111/joim.13140.

18. Kropacheva ES, Panchenko EP. The place of dabigatran in the treatment of patients with atrial fibrillation in the light of modern recommendations. Atherothrombosis. 2023;13(1):36-45. (In Russ.). doi: 10.21518/at2023-00.

19. Vorobyeva NM, Tkacheva ON. An Elderly Patient with Atrial Fibrillation: Ways to Enhance Safety of Anticoagulant Therapy. Doctor.Ru. 2019;10(165):16-22. (In Russ.). doi: 10.31550/1727-2378-2019-165-10-16-22.

20. Shlyakhto EV, Baranova EI, Ionin VA. Antithrombotic therapy for atrial fibrillation and comorbidities — how to choose the optimal solution? Russian Journal of Cardiology. 2021;26(12):4801. (In Russ.). doi: 10.15829/1560-4071-2021-4801.

21. Liu P. A comparative study of the clinical benefits of rivaroxaban and dabigatran in patients with nonvalvular atrial fibrillation with high bleeding risk. Front Cardiovasc Med. 2024 Sep 17;11:1445970. doi: 10.3389/fcvm.2024.1445970.

22. Runikhina NK, Cherniaeva MS, Malaya IP, et al. Enhanced STOPP/START Criteria: A Tool for Managing Polypharmacy in Older Population. Russian Journal of Geriatric Medicine. 2023;4(16):273-288. (In Russ.). doi: 10.37586/2686-8636-4-2023-273-288.

23. Gilyarevsky SR. Clinically Significant Drug Interactions for Direct Oral Anticoagulants: State of the Art. Rational Pharmacotherapy in Cardiology. 2022;18(3):332-341. (In Russ.). doi: 10.20996/1819-64462022-05-02.

24. Wiggins BS, Dixon DL, Neyens RR, et al. Select Drug-Drug Interactions With Direct Oral Anticoagulants: JACC Review Topic of the Week. J Am Coll Cardiol. 2020 Mar 24;75(11):1341-1350. doi: 10.1016/j.jacc.2019.12.068.

25. Dzhioeva ON, Rogozhkina EA, Drapkina OM. Perioperative Management of Patients Receiving Antithrombotic Therapy in Schemes and Algorithms. Rational Pharmacotherapy in Cardiology. 2022;18(6):717-726. (In Russ.). doi: 10.20996/1819-6446-2022-12-12.