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Anticoagulation in older adults

Section Editors
Lawrence LK Leung, MD
Kenneth E Schmader, MD
Deputy Editor
Jennifer S Tirnauer, MD


Most of the common cardiovascular disorders in older adults have a relationship to thrombosis, including ischemic heart disease, atrial fibrillation, valvular disease, and atherosclerotic vascular disease. Many of these patients require antithrombotic therapy, which raises questions regarding the appropriate use and safety of these agents, especially since older adults are at greater risk of anticoagulant-associated bleeding. The presence of concomitant physical and medical problems and the use of other drugs, especially the antiplatelet agents, increase the interactions and risks associated with anticoagulant therapy, requiring an assessment of the overall risk-benefit ratio [1].

Oral anticoagulation is commonly indicated in the following cardiovascular conditions:

Nonvalvular atrial fibrillation (see "Atrial fibrillation: Anticoagulant therapy to prevent embolization")

Cardioembolic stroke (see "Secondary prevention for specific causes of ischemic stroke and transient ischemic attack")

Valvular heart disease and prosthetic heart valves (see "Antithrombotic therapy for prosthetic heart valves: Indications")

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Literature review current through: Nov 2017. | This topic last updated: Mar 17, 2016.
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  1. Gage BF, Fihn SD, White RH. Warfarin therapy for an octogenarian who has atrial fibrillation. Ann Intern Med 2001; 134:465.
  2. Anderson FA Jr, Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med 1991; 151:933.
  3. Kannel WB, Belanger AJ. Epidemiology of heart failure. Am Heart J 1991; 121:951.
  4. McCrory DC, Matchar DB, Samsa G, et al. Physician attitudes about anticoagulation for nonvalvular atrial fibrillation in the elderly. Arch Intern Med 1995; 155:277.
  5. Kutner M, Nixon G, Silverstone F. Physicians' attitudes toward oral anticoagulants and antiplatelet agents for stroke prevention in elderly patients with atrial fibrillation. Arch Intern Med 1991; 151:1950.
  6. Man-Son-Hing M, Laupacis A. Anticoagulant-related bleeding in older persons with atrial fibrillation: physicians' fears often unfounded. Arch Intern Med 2003; 163:1580.
  7. Mungall D, White R. Aging and warfarin therapy. Ann Intern Med 1992; 117:878.
  8. Shepherd AM, Hewick DS, Moreland TA, Stevenson IH. Age as a determinant of sensitivity to warfarin. Br J Clin Pharmacol 1977; 4:315.
  9. Kagansky N, Knobler H, Rimon E, et al. Safety of anticoagulation therapy in well-informed older patients. Arch Intern Med 2004; 164:2044.
  10. Fang MC, Chang Y, Hylek EM, et al. Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation. Ann Intern Med 2004; 141:745.
  11. Gorin L, Fauchier L, Nonin E, et al. Antithrombotic treatment and the risk of death and stroke in patients with atrial fibrillation and a CHADS2 score=1. Thromb Haemost 2010; 103:833.
  12. Olesen JB, Lip GY, Hansen ML, et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ 2011; 342:d124.
  13. Olesen JB, Fauchier L, Lane DA, et al. Risk factors for stroke and thromboembolism in relation to age among patients with atrial fibrillation: the Loire Valley Atrial Fibrillation Project. Chest 2012; 141:147.
  14. Friberg L, Rosenqvist M, Lip GY. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J 2012; 33:1500.
  15. Hori M, Connolly SJ, Zhu J, et al. Dabigatran versus warfarin: effects on ischemic and hemorrhagic strokes and bleeding in Asians and non-Asians with atrial fibrillation. Stroke 2013; 44:1891.
  16. JCS Joint Working Group. Guidelines for pharmacotherapy of atrial fibrillation (JCS 2008): digest version. Circ J 2010; 74:2479.
  17. Inoue H, Okumura K, Atarashi H, et al. Target international normalized ratio values for preventing thromboembolic and hemorrhagic events in Japanese patients with non-valvular atrial fibrillation: results of the J-RHYTHM Registry. Circ J 2013; 77:2264.
  18. Mant JW, Richards SH, Hobbs FD, et al. Protocol for Birmingham Atrial Fibrillation Treatment of the Aged study (BAFTA): a randomised controlled trial of warfarin versus aspirin for stroke prevention in the management of atrial fibrillation in an elderly primary care population [ISRCTN89345269]. BMC Cardiovasc Disord 2003; 3:9.
  19. Mant J, Hobbs FD, Fletcher K, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007; 370:493.
  20. Hart RG, Pearce LA, Aguilar MI. Adjusted-dose warfarin versus aspirin for preventing stroke in patients with atrial fibrillation. Ann Intern Med 2007; 147:590.
  21. van Walraven C, Hart RG, Connolly S, et al. Effect of age on stroke prevention therapy in patients with atrial fibrillation: the atrial fibrillation investigators. Stroke 2009; 40:1410.
  22. Torn M, Bollen WL, van der Meer FJ, et al. Risks of oral anticoagulant therapy with increasing age. Arch Intern Med 2005; 165:1527.
  23. Wieloch M, Själander A, Frykman V, et al. Anticoagulation control in Sweden: reports of time in therapeutic range, major bleeding, and thrombo-embolic complications from the national quality registry AuriculA. Eur Heart J 2011; 32:2282.
  24. Hylek EM, Evans-Molina C, Shea C, et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation 2007; 115:2689.
  25. Poli D, Antonucci E, Marcucci R, et al. Risk of bleeding in very old atrial fibrillation patients on warfarin: relationship with ageing and CHADS2 score. Thromb Res 2007; 121:347.
  26. Singer DE, Chang Y, Fang MC, et al. The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Ann Intern Med 2009; 151:297.
  27. Hobbs FD, Roalfe AK, Lip GY, et al. Performance of stroke risk scores in older people with atrial fibrillation not taking warfarin: comparative cohort study from BAFTA trial. BMJ 2011; 342:d3653.
  28. Chen WT, White CM, Phung OJ, et al. Association between CHADS₂risk factors and anticoagulation-related bleeding: a systematic literature review. Mayo Clin Proc 2011; 86:509.
  29. Oldgren J, Alings M, Darius H, et al. Risks for stroke, bleeding, and death in patients with atrial fibrillation receiving dabigatran or warfarin in relation to the CHADS2 score: a subgroup analysis of the RE-LY trial. Ann Intern Med 2011; 155:660.
  30. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med 1994; 154:1449.
  31. Coon WW, Willis PW 3rd. Hemorrhagic complications of anticoagulant therapy. Arch Intern Med 1974; 133:386.
  32. Risks of long-term oral anticoagulant therapy in elderly patients after myocardial infarction. Second report of the Sixty Plus Reinfarction Study Research Group. Lancet 1982; 1:64.
  33. Levine MN, Raskob G, Hirsh J. Hemorrhagic complications of long-term anticoagulant therapy. Chest 1989; 95:26S.
  34. Froom P, Miron E, Barak M. Oral anticoagulants in the elderly. Br J Haematol 2003; 120:526.
  35. Fang MC, Go AS, Hylek EM, et al. Age and the risk of warfarin-associated hemorrhage: the anticoagulation and risk factors in atrial fibrillation study. J Am Geriatr Soc 2006; 54:1231.
  36. Gage BF, Birman-Deych E, Kerzner R, et al. Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall. Am J Med 2005; 118:612.
  37. Rosand J, Hylek EM, O'Donnell HC, Greenberg SM. Warfarin-associated hemorrhage and cerebral amyloid angiopathy: a genetic and pathologic study. Neurology 2000; 55:947.
  38. Fitzmaurice DA, Blann AD, Lip GY. Bleeding risks of antithrombotic therapy. BMJ 2002; 325:828.
  39. Knijff-Dutmer EA, Van der Palen J, Schut G, Van de Laar MA. The influence of cyclo-oxygenase specificity of non-steroidal anti-inflammatory drugs on bleeding complications in concomitant coumarine users. QJM 2003; 96:513.
  40. National Collaborating Centre for Chronic Conditions. Atrial fibrillation: national clinical guideline for management in primary and secondary care. London: Royal College of Physicians 2006.
  41. Kakar P, Lane D, Lip GY. Bleeding risk stratification models in deciding on anticoagulation in patients with atrial fibrillation: a useful complement to stroke risk stratification schema. Chest 2006; 130:1296.
  42. Eccles JT. Control of warfarin therapy in the elderly. Age Ageing 1975; 4:161.
  43. Routledge PA, Chapman PH, Davies DM, Rawlins MD. Factors affecting warfarin requirements. A prospective population study. Eur J Clin Pharmacol 1979; 15:319.
  44. Routledge PA, Chapman PH, Davies DM, Rawlins MD. Pharmacokinetics and pharmacodynamics of warfarin at steady state. Br J Clin Pharmacol 1979; 8:243.
  45. Schwartz JB, Kane L, Moore K, Wu AH. Failure of pharmacogenetic-based dosing algorithms to identify older patients requiring low daily doses of warfarin. J Am Med Dir Assoc 2011; 12:633.
  46. Palareti G, Hirsh J, Legnani C, et al. Oral anticoagulation treatment in the elderly: a nested, prospective, case-control study. Arch Intern Med 2000; 160:470.
  47. Ellis RJ, Mayo MS, Bodensteiner DM. Ciprofloxacin-warfarin coagulopathy: a case series. Am J Hematol 2000; 63:28.
  48. Jatoi A, Lennon C, O'Brien M, et al. Protein-calorie malnutrition does not predict subtle vitamin K depletion in hospitalized patients. Eur J Clin Nutr 1998; 52:934.
  49. Baillargeon J, Holmes HM, Lin YL, et al. Concurrent use of warfarin and antibiotics and the risk of bleeding in older adults. Am J Med 2012; 125:183.
  50. DiMarco JP, Flaker G, Waldo AL, et al. Factors affecting bleeding risk during anticoagulant therapy in patients with atrial fibrillation: observations from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Am Heart J 2005; 149:650.
  51. Lip GY, Karpha M. Anticoagulant and antiplatelet therapy use in patients with atrial fibrillation undergoing percutaneous coronary intervention: the need for consensus and a management guideline. Chest 2006; 130:1823.
  52. Zhao HJ, Zheng ZT, Wang ZH, et al. "Triple therapy" rather than "triple threat": a meta-analysis of the two antithrombotic regimens after stent implantation in patients receiving long-term oral anticoagulant treatment. Chest 2011; 139:260.
  53. Fosbol EL, Wang TY, Li S, et al. Safety and effectiveness of antithrombotic strategies in older adult patients with atrial fibrillation and non-ST elevation myocardial infarction. Am Heart J 2012; 163:720.
  54. Gage BF, Fihn SD, White RH. Management and dosing of warfarin therapy. Am J Med 2000; 109:481.
  55. Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:160S.
  56. Harrison L, Johnston M, Massicotte MP, et al. Comparison of 5-mg and 10-mg loading doses in initiation of warfarin therapy. Ann Intern Med 1997; 126:133.
  57. Crowther MA, Ginsberg JB, Kearon C, et al. A randomized trial comparing 5-mg and 10-mg warfarin loading doses. Arch Intern Med 1999; 159:46.
  58. Siguret V, Gouin I, Debray M, et al. Initiation of warfarin therapy in elderly medical inpatients: a safe and accurate regimen. Am J Med 2005; 118:137.
  59. Singla DL, Morrill GB. Warfarin maintenance dosages in the very elderly. Am J Health Syst Pharm 2005; 62:1062.
  60. Jacobs LG, Billett HH. Office management of deep venous thrombosis in the elderly. Am J Med 2009; 122:904.
  61. Moreau C, Pautas E, Gouin-Thibault I, et al. Predicting the warfarin maintenance dose in elderly inpatients at treatment initiation: accuracy of dosing algorithms incorporating or not VKORC1/CYP2C9 genotypes. J Thromb Haemost 2011; 9:711.
  62. Garcia D, Regan S, Crowther M, et al. Warfarin maintenance dosing patterns in clinical practice: implications for safer anticoagulation in the elderly population. Chest 2005; 127:2049.
  63. De Caterina R, Husted S, Wallentin L, et al. New oral anticoagulants in atrial fibrillation and acute coronary syndromes: ESC Working Group on Thrombosis-Task Force on Anticoagulants in Heart Disease position paper. J Am Coll Cardiol 2012; 59:1413.
  64. Apostolakis S, Sullivan RM, Olshansky B, Lip GY. Factors affecting quality of anticoagulation control among patients with atrial fibrillation on warfarin: the SAMe-TT₂R₂ score. Chest 2013; 144:1555.
  65. Roldán V, Cancio S, Gálvez J, et al. The SAMe-TT2R2 Score Predicts Poor Anticoagulation Control in AF Patients: A Prospective 'Real-world' Inception Cohort Study. Am J Med 2015; 128:1237.
  66. Pautas E, Peyron I, Bouhadiba S, et al. Reversal of overanticoagulation in very elderly hospitalized patients with an INR above 5.0: 24-hour INR response after vitamin K administration. Am J Med 2011; 124:527.
  67. Eikelboom JW, Wallentin L, Connolly SJ, et al. Risk of bleeding with 2 doses of dabigatran compared with warfarin in older and younger patients with atrial fibrillation: an analysis of the randomized evaluation of long-term anticoagulant therapy (RE-LY) trial. Circulation 2011; 123:2363.
  68. Tapson VF, Hyers TM, Waldo AL, et al. Antithrombotic therapy practices in US hospitals in an era of practice guidelines. Arch Intern Med 2005; 165:1458.
  69. Sudlow CM, Rodgers H, Kenny RA, Thomson RG. Service provision and use of anticoagulants in atrial fibrillation. BMJ 1995; 311:558.
  70. Turazza FM, Franzosi MG. Is anticoagulation therapy underused in elderly patients with atrial fibrillation? Drugs Aging 1997; 10:174.
  71. Brass LM, Krumholz HM, Scinto JM, Radford M. Warfarin use among patients with atrial fibrillation. Stroke 1997; 28:2382.
  72. Lip GY, Golding DJ, Nazir M, et al. A survey of atrial fibrillation in general practice: the West Birmingham Atrial Fibrillation Project. Br J Gen Pract 1997; 47:285.
  73. Gurwitz JH, Monette J, Rochon PA, et al. Atrial fibrillation and stroke prevention with warfarin in the long-term care setting. Arch Intern Med 1997; 157:978.
  74. Brass LM, Krumholz HM, Scinto JD, et al. Warfarin use following ischemic stroke among Medicare patients with atrial fibrillation. Arch Intern Med 1998; 158:2093.
  75. Fang MC, Go AS, Chang Y, et al. Thirty-day mortality after ischemic stroke and intracranial hemorrhage in patients with atrial fibrillation on and off anticoagulants. Stroke 2012; 43:1795.