Antiplatelet Therapy in Frail Elderly Patients with Atrial Fibrillation

Introduction to Antiplatelet Therapy

• The International Society on Thrombosis and Haemostasis states that concomitant administration of an oral anticoagulant with an antiplatelet agent increases bleeding risk, and the need for combined treatment should be reviewed 1

Bleeding Risk and Antiplatelet Therapy

• Age increases bleeding risk approximately two-fold in patients on anticoagulation, and adding antiplatelet therapy compounds this risk 2
• Poorly controlled hypertension and concomitant aspirin or NSAID use confer higher bleeding risk during anticoagulation 2

Management of Atrial Fibrillation

• The European Society of Cardiology emphasizes that bleeding risk scores should identify modifiable risk factors, not justify withholding appropriate anticoagulation 3
• The American Heart Association recommends continuing rivaroxaban monotherapy at the appropriate dose (15 mg daily if CrCl 30-49 mL/min, 20 mg daily if CrCl ≥50 mL/min) for frail patients with atrial fibrillation without recent ACS or stenting 1

Aspirin Therapy

• Aspirin provides inferior stroke prevention compared to oral anticoagulation in atrial fibrillation 4, 5
• The combination of oral anticoagulation with aspirin provides no additional stroke benefit but doubles bleeding risk 1

Optimizing Modifiable Bleeding Risk Factors

• Aggressively controlling blood pressure (target <140/90 mmHg, ideally <130/80 mmHg) is recommended 5
• Calculating CrCl at least annually using Cockcroft-Gault formula is recommended 1
• Reviewing all concomitant medications for drug interactions (particularly verapamil, amiodarone, clarithromycin, erythromycin) is recommended 1
• Avoiding NSAIDs is recommended 2