Bahrmann P, Christ M
Medizinische Klinik II, Asklepios Paulinen Klinik Wiesbaden, Geisenheimer Straße 10, 65197, Wiesbaden, Deutschland.
Institut für Biomedizin des Alterns, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Deutschland.
Herz. 2018 May;43(3):214-221. doi: 10.1007/s00059-017-4665-z.
Based on established risk scores, such as the CHADS-VASc score, the indications for oral anticoagulation are given for patients over 65 years old with atrial fibrillation and even more so for patients over 75 years old. Before beginning anticoagulation a geriatric assessment for evaluation of the cognitive ability, the activities of daily living and the risk of falling should be made because of the known complications of anticoagulation. Geriatric patients with non-valvular atrial fibrillation (AF) are increasingly being treated with non-vitamin K antagonist oral anticoagulants (NOAC) to prevent ischemic stroke. The European Society for Cardiology (ESC) guidelines for the management of AF recommended NOACs as the preferred treatment and vitamin K antagonists (VKA) only as an alternative option. Meanwhile, apixaban, rivaroxaban, and edoxaban as factor Xa inhibitors and dabigatran as a thrombin inhibitor, are more commonly used in clinical practice in patients with AF. Although, these drugs have pharmacodynamics and pharmacokinetic similarities and are often grouped together, it is important to recognize that the pharmacology and dose regimens differ between compounds. Especially in elderly patients the new drugs have interesting advantages compared to VKA, i. e., less drug-drug interactions with concomitant medication and a more favorable risk-benefit ratio mostly driven by the reduction of bleeding. Treatment of anticoagulation in elderly patients requires weighing the serious risk of stroke with an equally high risk of major bleeding and pharmacoeconomic considerations. The easier practicality of NOACs in routine practice must be emphasized as no international normalized ratio (INR) monitoring is necessary and the interruption of treatment for planned interventions is uncomplicated. A regular monitoring of the indications for NOACs is indispensable (as for all other medications). Especially elderly patients have the greatest benefit from NOAC along with a low renal elimination rate and they should certainly not be withheld from elderly patients who have a clear need for oral anticoagulation.
基于已确立的风险评分，如CHADS-VASc评分，对于65岁以上的房颤患者，甚至75岁以上的患者，都给出了口服抗凝治疗的指征。在开始抗凝治疗前，应进行老年综合评估，以评估认知能力、日常生活活动能力和跌倒风险，因为抗凝治疗存在已知的并发症。非瓣膜性房颤（AF）的老年患者越来越多地使用非维生素K拮抗剂口服抗凝药（NOAC）来预防缺血性卒中。欧洲心脏病学会（ESC）房颤管理指南推荐NOAC作为首选治疗药物，维生素K拮抗剂（VKA）仅作为替代选择。同时，阿哌沙班、利伐沙班和依度沙班作为Xa因子抑制剂，达比加群作为凝血酶抑制剂，在房颤患者的临床实践中应用更为普遍。尽管这些药物具有相似的药效学和药代动力学特性，常被归为一类，但重要的是要认识到不同化合物之间的药理学和剂量方案存在差异。特别是在老年患者中，与VKA相比，这些新药具有显著优势，即与合并用药的药物相互作用较少，且大多因出血风险降低而具有更有利的风险效益比。老年患者的抗凝治疗需要权衡卒中的严重风险与同样高的大出血风险以及药物经济学因素。必须强调NOAC在常规实践中更易于操作，因为无需监测国际标准化比值（INR），且计划干预时的治疗中断并不复杂。对NOAC的适应证进行定期监测是必不可少的（与所有其他药物一样）。特别是老年患者，肾清除率低，从NOAC中获益最大，对于明确需要口服抗凝治疗的老年患者，绝不应拒绝使用。
