When is anticoagulant therapy contraindicated

Older patients with atrial fibrillation were more likely to have high bleeding risk contraindications with oral anticoagulation and higher mortality compared with patients who were not treated with oral anticoagulation and did not have contraindications, according to a observational, longitudinal analysis published in JACC: Clinical Electrophysiology.

The use of oral anticoagulation in this older population reduced rates of hospitalization, stroke and death and increased the risk for intracranial hemorrhage , according to the study. Benjamin A. The primary analysis focused on contraindications and outcomes among patients not taking oral anticoagulation, whereas the secondary analysis focused on the use of oral anticoagulation and contraindications.

Patients with contraindications who were not treated with oral anticoagulation had worse bleeding and ischemic outcomes at 3 years compared with those who did not have contraindications. Disclosure s : The study was supported by a grant from Boston Scientific. Healio News Cardiology Arrhythmia Disorders. Source: Steinberg BA, et al. Of the remaining 84, patients eligible for anticoagulation, 8. Sixty-five percent of patients eligible for anticoagulation received warfarin, and the proportion was similar for patients with a relatively high risk of bleeding.

Conclusions: Older adults with atrial fibrillation rarely have absolute contraindications to oral anticoagulation therapy. Among patients without contraindications, most appeared to be eligible for any anticoagulant, and relatively high-risk features appeared not to influence warfarin use. Stroke risk was reduced from an untreated rate ranging from 4. Patients with absolute contraindications to warfarin anticoagulation therapy e.

These patients were systematically excluded from all RCTs of warfarin and atrial fibrillation. Based on this evidence, warfarin therapy is not indicated for low-risk patients but is beneficial in moderate- and high-risk patients.

Defining the exact risk for stroke is the critical task in determining if a patient should take warfarin see accompanying table. A relatively small but statistically significant risk for hemorrhage with warfarin therapy requires that individual patient characteristics be considered.

History or presence of no more than one of the following: CHF within days. American College of Chest Physicians 5. Information from references 4 through 7. In practice, the decision to anticoagulate with warfarin can be complex. However, patients at greatest risk for stroke often have a risk for hemorrhage or difficulty complying with warfarin therapy monitoring. In some patients, other antiplatelet and antithrombotic agents such as aspirin and clopidogrel Plavix remain a reasonable alternative.

Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Address correspondence by e-mail to Richard A. Guthmann, M. Reprints are not available from the author. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation.

Analysis of pooled data from five randomized controlled trials [published correction appears in Arch Intern Med ;]. Arch Intern Med. Anti-thrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis.