Antithrombotic Management of Elderly Patients With CAD
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The following are key points to remember from this state-of-the-art review on antithrombotic management of elderly patients with coronary artery disease (CAD):

1. Antithrombotic therapy represents the mainstay of treatment in patients with CAD, including elderly patients who are at increased risk for ischemic recurrences.

2. However, the elderly population is also more vulnerable to bleeding complications. Numerous mechanisms, including abnormalities in the vasculature, thrombogenicity, comorbidities, and altered drug response, contribute to both increased thrombotic and bleeding risk.

3. Age-related organ changes and drug-drug interactions secondary to polypharmacy lead to distinct pharmacokinetic and pharmacodynamic profiles of antithrombotic drugs.

4. Overall, these factors contribute to the risk-benefit profiles of antithrombotic therapies in elderly subjects and underscore the need for treatment regimens that can reduce bleeding while preserving efficacy.

5. Given that the prevalence of CAD, as well as concomitant diseases with thromboembolic potential such as atrial fibrillation increases with age and that the elderly population is in continuous growth, understanding the safety and efficacy of different antithrombotic regimens is pivotal for patient-centered care.

6. Risk stratification is key for patient-centered antithrombotic choice in the elderly and bleeding risk should guide the choice of antithrombotic strategies in the elderly.

7. General measures to mitigate bleeding include the use of radial access in patients undergoing percutaneous coronary intervention, close follow-up, use of proton pump inhibitors, avoidance of nonsteroidal anti-inflammatory drugs, and control of concomitant risk factors.

8. As bleeding causes are multifactorial and variable among elderly patients, an individual risk assessment should be performed in this population.

9. In general, the shortest possible duration of antiplatelet treatment should be considered in the elderly, when used in combination with oral anticoagulants. The ischemic benefit of extended dual antiplatelet therapy or rivaroxaban 2.5 mg–based dual-pathway inhibition may be counterbalanced by increased bleeding risk in the elderly and the benefit of these more intensive long-term secondary prevention strategies may be questionable among the frailest and oldest subpopulation, such as those residing in nursing homes.

10. At this time, the best evidence-based clinical judgment should guide decision making in elderly patients, but further studies are needed to specifically assess the impact of emerging antithrombotic strategies in elderly patients with CAD.

Source: https://www.jacc.org/doi/10.1016/j.jcin.2021.01.040?_ga=2.59388973.1879759314.1617783607-777820309.1584504539
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