Giugliano Robert P
Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, TIMI Study Office , Hale BTM, Suite 7022, 60 Fenwood Road, Boston, MA 02115, USA.
Eur Heart J Suppl. 2022 Feb 14;24(Suppl A):A1-A10. doi: 10.1093/eurheartj/suab150. eCollection 2022 Feb.
Elderly and frail patients with atrial fibrillation (AF) are at increased risk of thrombotic events, bleeding, and death compared to their counterparts, making their management challenging. With the introduction of non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) in the past decade, the risk:benefit balance in such high-risk patients with AF has tipped in favor of treating these patients with anticoagulation, and in most cases with a NOAC instead of a VKA. In patients ≥75 years of age with AF, each of the 4 approved NOACs reduced stroke or systemic embolism and vs warfarin in their landmark clinical trial and lowered mortality. However, only apixaban and edoxaban significantly reduced major bleeding vs warfarin. A similar pattern was seen in even older cohorts (≥80 and ≥85 years). Among patients age ≥80 who are not candidates for oral anticoagulants at the approved dose, edoxaban 15 mg may be a reasonable alternative. In elderly or frail individuals who are on multiple comedications (particularly if ≥1 moderate or strong cytochrome P-450 inhibitor), only edoxaban consistently reduced major bleeding compared to warfarin. Regardless of the specific OAC selected, appropriate dosing in the elderly (who frequently qualify for dose reduction per the prescribing label) is critical. In elderly and frail patients with AF, factors that may modify the efficacy-safety profile of specific oral OACs should be carefully considered to permit the optimal selection and dosing in these vulnerable patients.
与同龄人相比，老年及体弱的房颤（AF）患者发生血栓事件、出血和死亡的风险更高，这使得对他们的治疗颇具挑战性。在过去十年中，随着非维生素K拮抗剂（VKA）口服抗凝剂（NOACs）的引入，这类高危房颤患者的风险效益比已倾向于采用抗凝治疗，而且在大多数情况下是使用NOAC而非VKA进行治疗。在≥75岁的房颤患者中，4种已获批的NOACs在其标志性临床试验中均降低了中风或全身性栓塞的发生率，且与华法林相比降低了死亡率。然而，只有阿哌沙班和依度沙班与华法林相比显著降低了大出血的发生率。在年龄更大的队列（≥80岁和≥85岁）中也观察到了类似的模式。在年龄≥80岁且不适合使用获批剂量口服抗凝剂的患者中，15 mg依度沙班可能是一种合理的替代药物。在服用多种合并用药（特别是如果有≥1种中度或强效细胞色素P-450抑制剂）的老年或体弱个体中，与华法林相比，只有依度沙班持续降低了大出血的发生率。无论选择哪种特定的口服抗凝剂（OAC），对老年人进行适当给药（老年人通常符合处方标签中的剂量减少条件）都至关重要。在老年及体弱的房颤患者中，应仔细考虑可能改变特定口服OACs疗效-安全性概况的因素，以便在这些脆弱患者中进行最佳选择和给药。
