Use of anticoagulants for atrial fibrillation in older subjects across different countries: Cyprus, France, Netherlands, Norway

Atrial fibrillation (AF) is the most common arrhythmia in older adults, and those with AF have an increased risk of developing stroke. Although the use of anticoagulants for stroke prevention is strongly recommended, many older people are not appropriately treated. Vitamin K antagonists (VKA) have been the only available oral anticoagulants for such patients, but recently, new oral anticoagulants have been approved for stroke prevention in AF as an alternative to VKA. Some characteristics make them an attractive treatment option; however, many gaps in evidence remain, especially in the population of older patients. This paper explores the use of anti-thrombotic treatment for the prevention of stroke in AF in old subjects in four different European countries. VKA seems to be the standard therapy in older patients, although anti-platelet drugs are still used widely in some countries. In many European countries, warfarin is replaced by coumadin derivatives. The use of new oral anticoagulants seems to be quite limited in older subjects and some degree of discrimination exists in access to these new drugs. European Society of Cardiology (ESC) 2010 and 2012 guidelines seem to be triggering a wide change in attitudes and practices. Many countries are incorporating such guidelines into official recommendations, and specific country recommendations on the use of new anticoagulants have been published, partly due to the high economic impact of these drugs. Geriatricians still have a marginal role in the prescription of anticoagulants, which in most countries usually lies on cardiologists. General practitioners are key for follow-up, as the role of anticoagulation clinics remains relevant only in The Netherlands. Most old patients have limited knowledge of anticoagulant treatment options, thus, their involvement in decision-making is low.