Safety and efficacy of direct oral anticoagulants in very elderly patients with atrial fibrillation.

Background:
Atrial fibrillation (AF) significantly increases thromboembolic risk, particularly in the elderly. While direct oral anticoagulants (DOACs) reduce this risk, they elevate bleeding risk. This study evaluates the safety, efficacy, and predictors of bleeding and mortality in AF patients over 95 years old treated with DOACs.

Methods:
This retrospective study included AF patients ≥95 years old admitted to Meir Medical Center (2016–2021) who received DOACs. Major bleeding events were classified per the Bleeding Academic Research Consortium (BARC).

Results:
The study included 142 patients (mean age 96.6 ± 1.84 years, follow-up 33.4 ± 24 months). Major bleeding occurred in 17% of patients, including one case of cerebral bleeding. Patients with bleeding were younger (95.8 ± 1.7 vs. 96.85 ± 1.83 years, p = 0.009). Xarelto use was higher in the bleeding group (24.0% vs. 6.9%, p = 0.019), while Eliquis use was lower (70.8% vs. 87.2%, p = 0.062). Logistic regression identified younger age (OR = 0.624, p = 0.012) and prior PCI (OR = 2.846, p = 0.037) as predictors of bleeding.

The CVA/TIA incidence was 2.3% per patient year. Mortality was high (85.9%) with no significant difference between bleeding (88.0%) and non-bleeding (85.5%) groups (p = 0.741).

Conclusions:
DOAC-treated AF patients ≥95 years old have high risks of bleeding, stroke, and mortality. Eliquis may pose a lower bleeding risk compared to Xarelto. Treatment strategies should be individualized based on a risk-benefit assessment, with consideration of alternatives like left atrial appendage closure.