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(Stroke. 2005;36:705.)
© 2005 American Heart Association, Inc.
Letters to the Editor |
Stroke in the Very Elderly
Department of Internal Medicine, Hospital of Zumarraga, Spain
To the Editor:
Atrial fibrillation (AF) is the most common, potent, and independent risk factor for ischemic stroke,1 the incidence of which increases with age.2 To determine the influence of advanced age on anticoagulation therapy in elderly patients with AF, a retrospective cohort study of all patients admitted in our department (from 1995 to 2003) was conducted. These patients were >90 years of age and had had an acute stroke. The following parameters were analyzed: age, sex, cardiovascular risk factors and their treatment, and outcome. Among the 404 patients experiencing acute stroke, 39 (9.65%) were >90 years old (average age 91.73±2.34), and 82% were females. Four patients had cognitive impairment (Alzheimer disease) whose quality of life was average for their age. Major risk factors for stroke were AF (64%), hypertension (51%), and diabetes mellitus (7%). Smoking habits, before stroke or transient ischemic attack (TIA), had not been found. None of the patients with AF had been treated with anticoagulant drugs except 4 who received acetylsalicylic acid. However, all patients with hypertension or diabetes were receiving drugs. All episodes of stroke were ischemic (hemispheric 28; TIA 8; and lacunar 3). Thirteen patients died (12 in the first 72 hours), all of them with AF. The death rate among the elderly patients was 33.3% and 10.35% in the remaining patients diagnosed with acute stroke over the same time period. Seven patients fully recovered previous health state and functions, whereas 19 did not. After discharge, 14 patients with no AF received antiplaquetary drugs. In the remaining with AF, 4 received warfarin, 2 received antiplaquetary drugs (because of the refusal of the family to receive anticoagulants), and no treatment was received by 6 patients, all of whom had an important cognitive impairment and disability after stroke. Incidence of stroke increases with the age, and 75% of strokes occur in the elderly.3
AF is the most important single cause of ischemic stroke in this age group.4 Several clinical trials have demonstrated that warfarin sodium treatment reduces risk of stroke and death compared with placebo in persons with AF. In addition, this benefit is accompanied by a relatively low annual bleeding rate. Unfortunately, these findings have not been adequately implemented in clinical practice.1,3,5 Reduced odds of receiving warfarin is associated with the >85 age group, previous intracranial or gastrointestinal hemorrhage, or cognitive impairment.1 However, pharmacological treatment for risk factors such as hypertension, diabetes, heart failure, and dyslipemia are currently applied. Stroke has high rates of mortality (31% versus 16.7%) and disability (78% versus 48%) in the aged patient versus the younger one.2
We think that warfarin could reduce the stroke risk in persons with AF and should be used independent of age, especially in the elderly with other associated risk factors. This may be an opportunity to improve the quality of life and care of our elderly patients.
References
- Go AS, Hylek EM, Borowsky LH, Phillips KA, Selby JV, Singer DE. Warfarin use among ambulatory patients with non valvular atrial fibrillation: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study. Ann Intern Med. 1999; 12: 927–934.
- Olindo S, Cabré P, Deschamps R, Chatot-Henry C, Rene-Corail P, Fournerie P, Saint-Vil M, May F, Smadja D. Acute stroke in the very elderly: epidemiological features, stroke subtypes, management, and outcome in Martinique, French West Indies. Stroke. 2003; 34: 1593–1597.
[Abstract/Free Full Text] - Volpato S, Maraldi C, Ble A, Ranzini M, Rita Atti A, Dominguez LJ, Barbagallo M, Fellin R, Zuliani G; Gruppo Italiano di Farmacoepidemiologia nell’Anziano (GIFA). Prescription of antithrombotic therapy in older patients hospitalized for transient ischemic attack and ischemic stroke: the GIFA study. Stroke. 2004; 35: 913–917.
[Abstract/Free Full Text] - Hart RG, Halperin JL. Atrial fibrillation and stroke. Stroke. 2001; 32: 803–816.
[Free Full Text] - Smith NL, Psaty BM, Furberg CD, White R, Lima JA, Newman AB, Manolio TA. Temporal trends in the use of anticoagulants among older adults with atrial fibrillation. Arch Intern Med. 1999; 159: 1574–1578.
[Abstract/Free Full Text]
Response
Neurology Department, Neurovascular Unit, University Hospital Pierre Zobda-Quitman, Martinique, France
In their retrospective study of acute stroke patient admissions, Marti and Anton focused on the very elderly, >90 years of age. The majority (64%) exhibited atrial fibrillation (AF), but none were under warfarin before the stroke. The death rate was high in these very old patients, especially in AF patients. Physicians are usually reluctant to apply recommendations in elderly with AF because they fear hemorrhagic side effects of long-term use of warfarin.1 Although the risk of life-threatening hemorrhage is higher in elderly under anticoagulation, there is an alternative higher risk of ischemic stroke in AF patients >80 to 85 years, which overwhelms the former.2 Warfarin has been shown to reduce stroke rates by 68%.2 Therefore, as a rule, warfarin is mandatory in at-risk patients with AF, whatever their age. Neurologists have to make a special effort because they underuse anticoagulation compared with cardiologists.3 It was suggested in elderly AF patients to lower intensity of anticoagulation (international normalized ratio [INR], 1.5 to 1.9) in view of the balance between prevention of thromboembolism and the adverse effect by warfarin (ie, bleeding).4 However, in a recent retrospective study, INRs <2.0 were not associated with lower risk for intracranial hemorrhage compared with INRs between 2.0 and 3.0.5 Ximelagatran, a new oral direct thrombin inhibitor, might provide a more physician- and patient-friendly method of stroke prophylaxis, especially in the elderly.1 We must keep in mind that because of the rapidly aging population, physicians are challenged with more and more older patients with AF, for whom optimal prevention of stroke is crucial.
References
- Lepor NE. Changing the guard in long-term anticoagulation: clinical and economic implications. Rev Cardiovasc Med. 2004; 5 (suppl 5): S22–S29.
- Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med. 1994; 154: 1449–1457.[Abstract]
- Rahimi AR, Wrights B, Akhondi H, Richard CM. Clinical correlation between effective anticoagulants and risk of stroke: are we using evidence-based strategies? South Med J. 2004; 97: 924–931.[CrossRef][Medline] [Order article via Infotrieve]
- Yamaguchi T. Optimal intensity of warfarin therapy for secondary prevention of stroke in patients with nonvalvular atrial fibrillation: a multicenter, prospective, randomized trial. Japanese Nonvalvular Atrial Fibrillation-Embolism Secondary Prevention Cooperative Study Group. Stroke. 2000; 31: 817–821.
[Abstract/Free Full Text] - Fang MC, Chang Y, Hylek EM, Rosand J, Greenberg SM, Go AS, Singer DE. Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation. Ann Intern Med. 2004; 141: 745–752.
[Abstract/Free Full Text]
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