In the latest edition of the “Right Care Series” in the journal American Family Physician, primary care doctors Alan Roth and Andy Lazris, and patient partners Helen Haskell and John James describe some of the benefits and harms of giving blood thinners to older adults for atrial fibrillation, and how doctors and patients can work together to provide the right care for individual patients.
Atrial fibrillation (an irregular heart rhythm affecting the heart’s upper chambers, also known as “AFib”) is a common cardiac condition, affecting as many as 6 million people in the US and leading to 130,000 deaths per year, often due to strokes. Warfarin and other blood thinners are often prescribed to prevent strokes for patients with afib, but for older adults, clinicians need to be aware of the potential harms. Taking direct anticoagulants increases the risk of stomach and brain bleeds in older adults, events that can be particularly harmful after a fall.
How can clinicians help patients decide whether taking blood thinners is the right treatment for them? The authors recommend using risk stratification tools to determine an individual patient’s risk for stroke as well as their risk for bleeding and falls. Then clinicians and patients should discuss the pros and cons of treatment options to come to a shared decision.
In the case of blood thinners for afib in older adults, shared decision making is especially important because there is no clear “right answer” for all patients.
In the case of blood thinners for afib in older adults, shared decision making is especially important because there is no clear “right answer” for all patients. For example, a 2007 Cochrane review found no difference in all-cause mortality between patients with afib taking warfarin and those taking placebo (the anticoagulant group experienced 5 out of 1000 disabling or fatal strokes, but 6 out of 1000 fatal bleeds). The lack of clinical trials of anticoagulants including older patients with comorbidities makes it even tougher to evaluate harms and benefits as well.
The authors identify questions that patients will likely want to have answered in these shared decision making conversations, and thus ones that doctors should take into consideration. For example, what are the differences between warfarin and other anticoagulant drugs? How safe is surgery for a patient taking anticoagulants? Can a patient who starts on anticoagulants stop taking them at some point? Patient partners Haskell and James write, “The goal of patients is their global well-being, a goal that does not necessarily align with the optimal end point for each of their medical conditions. It is the fundamental role of the primary care physician to balance these conflicting concerns.”
For more on the benefits and harms of anticoagulants, read the full Right Care article.