Incidence of major bleeding events and outcome of patients of 80 and 90 years or older with ongoing anticoagulants: five-year survey in northwest Tuscany
Authors: Conti A , Bogazzi I.C , Mazzucchelli M , Covelli A , Molesti D , Catarzi S , Renzi N , Panpana A , Tomisti L , Leorin M , Ghiadoni L 
Published: November 2020

Abstract

Objective
To search for rates of major bleeding events in patients (pts) with age ≥80 or ≥90 years (y.) with ongoing anticoagulants referred to hospital.

Methods
Patients complaining any bleeding events were submitted to propensity score matching for major bleeding and stratified according to age ≥80 or ≥90 y. and warfarin or direct oral anticoagulants (DOACs).

Setting
A General Hospital, northwest Tuscany, five-year survey, 385,650 visits; catchment area 197,722 inhabitants, of whom 18,373 on warfarin and 14,808 on DOACs. Out of DOACs, dabigatran and rivaroxaban were available in the catchment area since 5 y., apixaban 4 y. and edoxaban 3 y; 5,553 pts received rivaroxaban, 4,602 dabigatran, 3,147 apixaban and 1,506 edoxaban.

Endpoint
Primary endpoint was one-week death, and incidence of major bleeding.

Results
Out of 7,474 pts considered, 2504 (33.5%) pts were older than 80 y., of whom 518 (6.8%) were older than 90 y; they were enrolled in the study. Overall, 253 (10.1%) showed history of stroke/TIA, 578 (22.9%) atrial fibrillation, 277 (11.1%) cancer, 177 (7.0%) congestive heart failure, 33 (1.3%) pulmonary thromboembolism.
Of these 7,474 pts 1,040 (41.5%) showed major bleeding: 621 (24.8%) were gastrointestinal of which 258 (10.3%) of the upper tract and 363 (14.5%) of the lower tract; 794 (31.7%) were brain haemorrhage; the remaining patients showed other bleeding.
Overall, 435 (5.8%) pts needed reversal anticoagulation, 325 (4.4%) red blood cell pack, and 2879 (38.5%) admission. Eventually, 127 pts have been readmitted to the hospital for ischemic stroke and 499 for new bleeding event. CHA2D2VASc-score was 2.5±1.5 and Charlston Comorbidity Index was 3.4±2.3.
Out of 2,504 patients older than 80 y., 367 (14,7%) received anticoagulants (including heparin) of which 134 (5.4%) received warfarin versus 63 (2.5%) DOACs (p&lt;0.001); 24 dabigatran, 19 rivaroxaban, 17 apixaban, and 3 edoxaban. Overall 88 (3.5%) needed reversal anticoagulation, 128 pts (5.1%) red blood cell pack, and 825 (32.9%) pts admission.
One-week mortality rate as follows: anticoagulants 35 (1.4%) versus DOACs 6 (0.2%), p&lt;0.001; dabigatran 0, rivaroxaban 2, apixaban 2, edoxaban 2.
Out of 518 patients older than 90 y., 98 (18.9%) received anticoagulants (including heparin) of whom 44 (8.5%) received warfarin; 11 (2.1%) DOACs (p&lt;0.001); 4 dabigatran, 2 rivaroxaban, 4 apixaban, and 1 edoxaban. Overall 24 (4.6%) needed reversal anticoagulation, 50 (9.7%) red blood cell pack, and 203 (39.2%) admission.
One-week mortality rate as follows: anticoagulants 10 (1.9%) versus DOACs 1 (0.2%), p&lt;0.001; dabigatran 0, rivaroxaban 0, apixaban 1 (0.2%), edoxaban 0.

Conclusion
Patients of 80 y. and even 90 y. or older, with ongoing warfarin, showed higher percentage of major bleeding events and mortality rate versus DOACs. Within DOACs, edoxaban was more likely to show lower rate of major bleeding events, without differences in death rate.

Funding Acknowledgement
Type of funding source: None