Anticoagulation for Non-Valvular Atrial Fibrillation in Older People

Atrial fibrillation (AF) is a common arrhythmia that increases in prevalence with advancing age. Systemic thromboembolism, a complication of AF and ischaemic stroke, is the most frequent clinical manifestation. The risk of stroke is increased in the presence of factors such as advancing age, heart failure, hypertension, diabetes and history of stroke. Long-term anticoagulation with warfarin has been the standard treatment for stroke prevention in patients with AF. In older people anticoagulation is associated with an increased risk of bleeding. Therefore, managing AF in older people can be a clinical challenge because not only are they at a high risk of thromboembolism but also of bleeding. Stroke risk stratification schemes have been developed to guide assessment of risks versus benefits. Other considerations in older people include monitoring anticoagulation, and assessing falls risk, compliance and the potential for drug interactions. A range of novel oral anticoagulants, such as direct thrombin inhibitors and factor Xa inhibitors, have been developed. These anticoagulants have demonstrated advantages in safety, efficacy and convenience of use in large randomised clinical trials. These novel anticoagulants could provide alternatives to warfarin for preventing stroke in older people with AF.