The safety and efficacy of non-vitamin K antagonist oral anticoagulants in atrial fibrillation in the elderly

Atrial fibrillation (AF) is the most common arrhythmia and its prevalence increases with age. Age also increases the risk of thromboembolism related to AF. As a result, elderly patients are at increased risk of AF-related stroke compared to younger patients. Age, however, also increases the risk of bleeding, including that of intracranial haemorrhage, an important cause of death and disability. Elderly patients with AF are, therefore, often undertreated due to the fear of bleeding complications, although recent data suggest an even greater net clinical benefit for anticoagulation in general in the elderly, even the very elderly, compared with younger patients. The non-vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran, rivaroxaban, apixaban and edoxaban, have become popular alternatives to vitamin K antagonists (VKAs) for anticoagulation in AF. The improved safety profile of NOACs may enable treatment of elderly patients that were previously untreated, further improving on this net clinical benefit. However, a number of factors, including renal impairment and multiple comorbidities, may elicit in elderly patients concerns with NOACs that are not seen in younger patients. Recent clinical data suggest that the use of NOACs offers a safer alternative to VKAs. However, on the basis of current evidence, it is not possible to simply recommend one NOAC over another in elderly adults. A personalised approach is recommended, accounting for individual patient factors.