Do we need to do a better job of undertaking antithrombotic therapy in the elderly?

The increasing prevalence of atrial fibrillation in the elderly, especially compared with younger age groups, is striking (8% in persons > 80 years compared with 1% in those < 60 years).¹ This arrhythmia presents several management problems for physicians that are intensified in the elderly. In general, patients over age 65 have medication compliance issues, and having chronic atrial fibrillation certainly compounds this problem. Affected patients will usually require medication to control the ventricular rate and with few exceptions nearly always require either aspirin or warfarin (or in some cases the newer heparin preparations) to minimize the incidence of thromboembolic events, especially ischemic strokes (which are the most devastating complication of atrial fibrillation).

In their study, Monte et al studied a cohort of 1812 patients > 65 years who were discharged over a 12-month period from Italian hospitals with a primary or secondary diagnosis of atrial fibrillation, and followed for a period of up to a year. The authors were interested in learning how patients were treated in-hospital and the effectiveness of postdischarge compliance to hospital-initiated antithrombotic regimens, and what effect this compliance (or noncompliance in many cases) had on clinical outcome. Monte et al found that anticoagulants were not prescribed for up to two thirds of patients following hospitalization with atrial fibrillation—a disturbing finding in and of itself. Moreover, most of the patients who did not receive anticoagulation therapy also did not receive antiplatelet agents, although aspirin is often useful.² As expected, those patients receiving either warfarin or aspirin had a significant reduction in total mortality over the follow-up period, as well as in a reduction in thromboembolic events.

What is to account for this under use of antithrombotic therapy in an elderly population, and how can it be corrected? There is no simple answer. What makes this dilemma harder to understand in the population studied is the fact that all treatments and office visits were fully reimbursable and easily accessible under Italy's national health system. Despite this, both doctors and patients bear responsibility for the underutilization. (This situation, by the way, is not unique to Italy.³) Although I understand the concerns of the elderly patient about internal bleeding after falling (this age group is prone to falls, after all), it is up to the physician to reassure patients that antithrombotic therapy should be undertaken in all but a minority of elderly patients with atrial fibrillation because it can help prevent crippling strokes. This is a public health education issue of the highest magnitude and should be treated as such.