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Oral anticoagulant therapy safely prevented stroke in older patients with atrial fibrillation
Evidence-Based Medicine, 10/26/09

Dunn A – In patients with atrial fibrillation, the effectiveness of antiplatelet therapy for stroke prevention decreased with age, but that of oral anticoagulants did not. Relative risk of serious bleeding with oral anticoagulants was not affected by age.

Methods

Individual patient data meta–analysis of 12 randomised controlled trials (RCTs). 6 RCTs were placebo–controlled; 8 RCTs compared an oral anticoagulant (OAC) with an antiplatelet (AP).
Patients: 8932 adults (mean age 72 y, 63% men) with non–valvular atrial fibrillation. Patients with clinical indications for or against any of the active therapies were excluded.
Interventions: full–dose OACs (mainly warfarin sodium or 4–hydroxycoumarin) with lower target international normalised ratio (INR) of 1.5–2.8 and upper target INR of 2.7–4.2 (n = 3430); APs (mainly acetylsalicylic acid, 75–325 mg) with or without low–dose OACs (median INR <1.5; n = 3531); or placebo (n = 1971).
Outcomes: ischaemic stroke, serious bleeding, and cardiovascular events (ischaemic stroke, myocardial infarction, systemic embolism, or vascular death). Intention–to–treat analysis.

Results

Older age was associated with increased risk of all outcomes.
Independent of age and other covariates, both OACs and APs decreased risk of stroke and cardiovascular events compared with placebo; OACs, but not APs, increased risk of serious bleeding.
The treatment effect of OACs decreased slightly in older patients: The adjusted hazard ratio for ischaemic stroke with OAC use was 0.22 at age 50 years and 0.53 at age 90 years.
In contrast, the treatment effect of APs decreased considerably in older patients: The adjusted hazard ratio for ischaemic stroke with AP use was 0.40 at age 50 years, gradually increasing until it exceeded 1 at about age 82 years and reaching 1.25 at age 90 years.
Age did not influence the effect of treatment with either drug on serious bleeding or cardiovascular events.

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