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J Am Coll Cardiol, 2009; 54:999-1002, doi:10.1016/j.jacc.2009.05.046
© 2009 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Bleeding Risk During Oral Anticoagulation in Atrial Fibrillation Patients Older Than 80 Years

Daniela Poli, MD*,{dagger},*, Emilia Antonucci, MS*,{dagger}, Elisa Grifoni, MD*,{dagger}, Rosanna Abbate, MD*,{dagger}, Gian Franco Gensini, MD*,{dagger},{ddagger} and Domenico Prisco, MD*,{dagger}

* Department of Medical and Surgical Critical Care, University of Florence, Florence, Italy
{dagger} Department of Heart and Vessels, Thrombosis Centre, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
{ddagger} Centro S. Maria agli Ulivi, Fondazione Don Carlo Gnocchi Onlus IRCCS, Impruneta, Florence, Italy

Manuscript received March 13, 2009; revised manuscript received May 6, 2009, accepted May 25, 2009.

* Reprint requests and correspondence: Dr. Daniela Poli, Centro di Riferimento Regionale per la Trombosi, Azienda Ospedaliera Universitaria Careggi, V.le Morgagni 85-50134 Firenze, Italy (Email: polida{at}aou-careggi.toscana.it).

Objectives: We sought to evaluate the rate of bleeding in relation to age (<80 and ≥80 years), the quality of anticoagulation (expressed as time spent in international normalized ratio therapeutic range), and factors associated with bleeding events.

Background: Stroke prevention in patients with atrial fibrillation (AF) is an increasingly crucial public health target, particularly in patients ages ≥80 years.

Methods: We conducted a prospective observational study on 783 patients with AF on oral anticoagulant treatment (OAT).

Results: Patients spent a median 14%, 71%, and 15% of time below, within, and above the intended therapeutic range, respectively. No difference in OAT quality was found between patients age <80 and ≥80 years. During follow-up, 94 patients experienced bleeding complications (rate 3.7 x 100 patient/years), 37 major (rate 1.4 x 100 patient/years), and 57 minor (rate 2.2 x 100 patient/years). Different rates of major hemorrhage were observed between patients age <80 and ≥80 years (0.9 vs. 1.9 x 100 patient/years; p = 0.004). Bleeding risk also was greater in patients with a history of previous cerebral ischemic event (odds ratio [OR]: 2.5; 95% confidence interval: 1.3 to 4.8; p = 0.007). A Cox regression analysis confirmed age ≥80 years associated with bleeding risk (OR: 2.0).

Conclusions: These results indicate that the rate of major bleeding complications may be kept acceptably low also in very elderly AF patients on OAT, provided a careful management of anticoagulation is obtained.

Key Words: atrial fibrillation • bleeding • elderly • quality of anticoagulation • warfarin

Abbreviations and Acronyms
  AF = atrial fibrillation
  CHADS2 = congestive heart failure, age, diabetes, previous stroke
  CI = confidence interval
  INR = international normalized ratio
  OAT = oral anticoagulant treatment
  OR = odds ratio
  TIA = transient ischemic attack


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