Antithrombotic therapy in the elderly: expert position paper of the European Society of Cardiology Working Group on Thrombosis

Contemporary medicine is shifting towards person rather than disease-oriented care.1 With increasing life expectancy and the ageing of baby boomers, the proportion over 60 years is growing faster than the overall population, with worldwide estimates reaching 2 billion by 2050 (http://www.un.org/esa/population/publications/worldageing19502050).2 In parallel, acute coronary syndromes (ACS) and atrial fibrillation (AF)—the most frequent indications for dual platelet inhibition or anticoagulation—occur mostly in older patients.2–6 There is general agreement that people ≥75 years can be defined ‘elderly’; however, cutoffs as low as 65 years have been applied to important clinical datasets and risk scores.3,7–10 Moreover, ageing is a continuous process and life-span expansion is deflating (http://www.nber.org/papers/w18407). For these reasons, a threshold to define ‘elderly’ has been intentionally avoided in this document. Of note, over one third of patients admitted with acute myocardial infarction (MI) and two thirds dying from MI are over 75 years, but <7% of patients in ACS trials are reported ≥75 years.11 Older patients have multi-organ changes, increased risk of both bleeding and ischaemic events,3,5,12 frequent comorbidities/comedication, and reduced adherence to prescriptions. Given the challenges of antithrombotic treatment in the elderly, the European Society of Cardiology (ESC) Working Group on Thrombosis gathered a task group to address the topic. Antiplatelet, anticoagulant, and fibrinolytic drugs can prevent, postpone, or attenuate the severity of thrombotic events—namely stroke, transient ischaemic attack (TIA), MI, systemic embolism (SE), deep vein thrombosis (DVT), or pulmonary embolism (PE)—and retard cardiovascular and all-cause death, but at the cost of increased bleeding. The critical conundrum is whether, in the older patient, the benefits outweigh the …