When to consider stopping anticoagulation in a patient with atrial fibrillation (afib) and multiple falls who is anticoagulated?

From the Guidelines

Anticoagulation in patients with atrial fibrillation and multiple falls should not be stopped unless the patient has experienced traumatic falls with serious bleeding, has very high fall risk (>4-5 falls per year), or has suffered intracranial hemorrhage, as the stroke risk typically outweighs the bleeding risk from falls in most patients. When considering stopping anticoagulation, the CHA₂DS₂-VASc score should be calculated to assess stroke risk 1. For patients at truly prohibitive bleeding risk, alternatives include left atrial appendage occlusion devices, reduced doses of direct oral anticoagulants (DOACs) such as apixaban 2.5mg twice daily or rivaroxaban 15mg daily, or aspirin 81-325mg daily (though this provides minimal stroke protection) 1.

Key Considerations

• The decision to stop anticoagulation should be individualized based on careful risk-benefit assessment, taking into account the patient's stroke risk and bleeding risk 1.
• Fall prevention strategies should be implemented concurrently, including physical therapy, home safety evaluation, vision assessment, medication review, and appropriate assistive devices.
• The decision requires shared decision-making with the patient, considering their values and preferences regarding stroke prevention versus bleeding risk.

Management of Anticoagulation

• For patients who require temporary interruption of anticoagulation, the duration of interruption and timing of resumption of anticoagulation after the procedure should be guided by individualized consideration of the risk of thrombotic events and the severity of the operative and perioperative bleeding risk 1.
• Bridging with unfractionated heparin or low-molecular-weight heparin may be considered for patients at higher risk of thromboembolism, although data for low-molecular-weight heparin are limited 1.

Alternatives to Anticoagulation

• Left atrial appendage occlusion devices may be considered for patients at prohibitive bleeding risk 1.
• Reduced doses of direct oral anticoagulants (DOACs) such as apixaban 2.5mg twice daily or rivaroxaban 15mg daily may be considered for patients at prohibitive bleeding risk 1.
• Aspirin 81-325mg daily may be considered for patients at prohibitive bleeding risk, although this provides minimal stroke protection 1.

From the FDA Drug Label

The risk-benefit should be reassessed periodically in patients who receive indefinite anticoagulant treatment.

The decision to stop anticoagulation in a patient with atrial fibrillation and multiple falls should be based on a reassessment of the risk-benefit ratio of continuing anticoagulant treatment.

• Key factors to consider include the patient's individual risk of stroke and systemic embolism, as well as their risk of bleeding and falls.
• Clinical judgment is necessary to determine whether the benefits of anticoagulation outweigh the risks in this patient.
• Periodic reassessment of the patient's condition and adjustment of their treatment plan as needed is recommended 2.

From the Research

Considerations for Stopping Anticoagulation in AFib Patients with Multiple Falls

When considering stopping anticoagulation in a patient with atrial fibrillation (AFib) and multiple falls, several factors must be taken into account.

• The risk of stroke and thromboembolic events must be weighed against the risk of bleeding, particularly intracranial hemorrhage 3, 4.
• Patients with a history of falls are at a higher risk of major bleeding, including intracranial hemorrhage, and mortality 5, 6.
• The use of non-vitamin K oral anticoagulants (NOACs) such as dabigatran and apixaban may be associated with a lower risk of intracranial hemorrhage compared to warfarin 5, 6.

Risk Assessment and Management

• A thorough risk assessment, including the CHA2DS2-VASc and HAS-BLED scores, should be performed to determine the individual patient's risk of stroke and bleeding 6.
• The decision to stop anticoagulation should be made on a case-by-case basis, taking into account the patient's overall health status, fall risk, and other comorbidities 4, 7.
• Strategies to reduce the risk of falls, such as physical therapy and home safety assessments, should be implemented to minimize the risk of bleeding in patients with AFib who are receiving anticoagulation therapy 4.

Current Research and Guidelines

• There is ongoing research to determine the best approach to managing anticoagulation in patients with AFib and a history of falls or risk of falls 7.
• Current guidelines recommend individualized assessment and management of patients with AFib, taking into account their unique risk factors and comorbidities 3, 4.