Anticoagulation therapy in older patients at risk for syncopal and not-syncopal fall and/or frailty. An AcEMC-GIMSI multidisciplinary consensus document

Abstract

In aged patients, the most frequent indications for anticoagulation are atrial fibrillation (AF) and venous thromboembolism for stroke and systemic embolism prevention. Despite systemic anticoagulation recommended by current guidelines for patients over 65 years, in clinical practice up to 50 % of elderly patients do not receive maintenance anticoagulation therapy. This is particularly evident in frail subjects at risk of syncopal and not-syncopal fall, fearing intracranial bleeding following a fall. As the risk of bleeding associated with falls is still debated, the boards of the Academy of Emergency Medicine and Care (AcEMC) and the Italian Multidisciplinary Working Group on Syncope (GIMSI), in order to write a consensus document, submitted to a panel of experts eight statement which could represent as many controversial topics for anticoagulant prescription in patients over 75 years. The Delphi method was used to obtain consensus between 15 physicians from different medical specialties; some of them were expert in syncope management and worked in a Syncope Unit. All had experience in prescribing oral anticoagulation. A questionnaire was sent on the appropriateness of oral anticoagulation in eight clinical situations where the risk of fall is present (frailty, cognitive impairment, previous falls, absence of caregiver, chronic renal impairment, nonvalvular AF with HAS-BLED score ≥3 or CHA2DS2-VASc score ≥3). All experts completed the questionnaire within three rounds and the consensus was reached on many but not all statements, leaving room for debate on some clinical situations. The consensus document gives useful advice for elderly patients’ management, who need oral anticoagulant therapy but are at risk of syncopal or not-syncopal fall. Nonetheless, there are some unresolved issues where an individual decision should be taken by the physician in agreement with the patient.

Keywords

• Anticoagulation therapy
• atrial fibrillation
• venous thromboembolism
• syncope
• accidental falls
• hemorrage