Abstract
Introduction
Novel oral anticoagulants (NOACs) expanded the options for stroke prevention in atrial
fibrillation (AF). Earlier studies comparing their relative effectiveness and safety
typically do not incorporate age-related differences or postmarketing studies. This
study aimed to summarize and compare clinical and safety outcomes of oral antithrombotics
for stroke prevention in AF in younger (65–74 years) and older (≥75 years) elderly.
Methods
We searched PubMed, Embase, and The Cochrane Library from inception through May 1,
2015, for randomized and nonrandomized studies comparing NOACs, warfarin, and aspirin
in elderly with AF. Stroke and systemic embolism (SSE) and major bleeding (MB) are
the main outcomes. We also studied secondary outcomes of ischemic stroke, all-cause
mortality, intracranial bleeding, and gastrointestinal bleeding.
Results
Of 5255 publications identified, 25 randomized controlled trials and 24 nonrandomized
studies of 897,748 patients were included. NOACs reduced the risk of SSE compared
with warfarin (rate ratios [RRs] range from 0.78–0.82). Relative to SSE, NOACs demonstrated
a smaller benefit for ischemic stroke (dabigatran 110 mg, RR 1.08; edoxaban, 1.00;
apixaban, 0.99). On the contrary, aspirin was associated with a significantly higher
risk of SSE, ischemic stroke, and mortality than warfarin or NOACs (RR > 1), particularly
in older elderly. Regarding safety, medium-dose aspirin (100–300 mg daily) and aspirin/clopidogrel
combination showed an increased risk of MB compared with warfarin (RR 1.17 and 1.15,
respectively), as per dabigatran 150 mg and rivaroxaban in older elderly (RR 1.17
and 1.12, respectively). Among the NOACs, dabigatran 150 mg conferred greater gastrointestinal
bleeding risk compared with warfarin (RR 1.51), whereas rivaroxaban (RR 0.73) demonstrated
less benefit of reduced intracranial bleeding than other NOACs (RRs range 0.39–0.46).
Conclusions
Lower rates of SSE and intracranial bleeding were observed with the NOACs compared
with warfarin. Dabigatran 150 mg and rivaroxaban were associated with higher rates
of MB in older elderly.
Keywords
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Article info
Publication history
Published online: October 30, 2015
Footnotes
L.L. and W.S.L. contributed equally to this article.
The authors declare no conflicts of interest.
Identification
Copyright
© 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.
