Title: Anticoagulating Elderly Patients in Atrial Fibrillation
Abstract: The recent article in CHEST, by Drs. Marine and Goldhaber (April 1998),1Marine JE Goldhaber SZ Controversies surrounding long-term anticoagulation of very elderly patients in atrial fibrillation..Chest. 1998; 113: 1115-1118Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar is well-reasoned. There are indeed great hazards in anticoagulating elderly patients. However, significant hazards exist in any group of patients requiring anticoagulation. Unfortunately, aspirin is only about 20% effective in preventing platelet aggregation compared to coumadin. New drugs are or will be available that may add a modest increase to the efficacy of aspirin. In my own experience, most elderly patients cardioverted from atrial fibrillation will not maintain sinus rhythm or will require one or more antiarrhythmic drugs that also have very serious adverse effects and may be very expensive. Since a number of patients do not recognize recurrence of atrial fibrillation, they are then exposed to the risk of stroke if not anticoagulated. Obviously, in any patient on coumadin, close supervision of the prothrombin time and international normalized ratio (INR) is essential. I have always experienced a great deal of anxiety with my anticoagulated patients. Over many years, I have had two patients under 60 years of age with prosthetic valves, with anticoagulation carefully controlled, die of massive cerebral hemorrhage, and one patient under 70 years of age with a prosthetic valve recover from a massive subdural hemorrhage. In the last 2 years, in clinical research projects, I have lost one 74-year-old patient with a massive cerebral hemorrhage with INR maintained about 2.2. During this same period, I have seen two patients who succumbed to cerebral embolism with atrial fibrillation before they could be brought under anticoagulation. AFFIRM (atrial fibrillation follow-up study sponsored by NHLBI), a 5-year, two-arm study comparing rate control vs rhythm control with all rate control patients anticoagulated and probably the majority of rhythm control patients anticoagulated (age ≥65 unless having a major risk factor), may provide valuable information to help answer the questions posed by the authors. I certainly agree with the need for a major study looking at aspirin (with or without one of the newer antiplatelet drugs) vs coumadin in the very elderly group discussed.