Nevertheless, concerns have remained about the risk of bleeding when used in very elderly patients and limited clinical trial and real-world data are available for this age group. This is compounded by elderly patients being commonly associated with multimorbidity, frailty and polypharmacy, with implications for anticoagulation options.2)3)4) Hence, balancing thromboembolism prevention and the risk of bleeding is paramount.

In this issue of the journal, the study by Choi et al.5) provides a critical evaluation of the efficacy and safety of NOACs compared to aspirin or non-use in this vulnerable population using the data from the Korean National Healthcare Insurance registry.5) A total of 10,625 AF patients aged 85 and older without a history of intracranial hemorrhage, gastrointestinal bleeding, or prior prescription of aspirin, warfarin, or NOACs were analysed between 2015 and 2020. NOAC use in these elderly patients demonstrated significantly reduced risk of stroke or systemic embolism in comparison with aspirin use (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.60–0.85; p<0.001) and non-use (HR, 0.60; 95% CI, 0.53–0.69; p<0.001). Despite a higher incidence of bleeding in the NOAC group (HR, 1.25; 95% CI, 1.07–1.56; p=0.006), there was no corresponding increase in mortality (HR, 0.60; 95% CI, 0.45–0.81; p<0.001). Hence, NOACs provide a net clinical benefit in preventing thromboembolic events without significantly increasing the risk of bleeding-related death.

This study by Choi et al.5) provides evidence supporting the continuation of anticoagulation in very elderly AF patients. With advancing age, the delicate balance between preventing thromboembolic events and minimizing avoidable bleeding risks becomes even more challenging. As can be seen from the fact that the non-use group accounted for more than half of the total participants (56.2%) included in analysis and the remaining half were prescribed aspirin, while only about a quarter of total were taking NOACs (24.7%), which reflects real-world clinical practice of low anticoagulation use in very elderly patients in Korea.

Managing anticoagulation in very elderly patients is complicated by the fact that even those without initial bleeding complications are at higher risk as they age, necessitating regular reassessment of the risk-benefit ratio of continued anticoagulation therapy. This clinical conundrum highlights the importance of real-world evidence, such as that provided by Choi et al.,5) to guide nuanced decision-making in this growing very elderly population.

Similarly, percutaneous left atrial appendage occlusion (LAAO) can be considered as viable options in very elderly patients who are at high risk of bleeding or cannot tolerate long-term anticoagulation. Although LAAO is not without its own procedural risks, age alone should not preclude LAAO because it delivered similar benefits as their younger counterparts.6) What is common and more important in both NOACs and LAAO is that appropriate stroke prevention is necessary and beneficial even in very elderly AF patients.

This study’s robust use of a large national cohort lends considerable weight to its findings, offering a valuable insight into the real-world consequences of anticoagulation use among those who live the longest. Given the increasing prevalence of AF in the aging population, the implications of this study extend beyond the academic realm, have implications for clinical practice. The findings support the broader adoption of NOACs as the preferred anticoagulation strategy in very elderly patients, emphasizing the need for vigilant monitoring to balance the benefits of stroke prevention with the potential risk for bleeding complications.

Nevertheless, several limitations warrant consideration. The retrospective nature of the data introduces potential biases, including selection and survival biases, which may affect the generalizability of the results. Moreover, the study population was exclusively Korean, which may limit the applicability of the findings to other ethnic and genetic backgrounds, given the racial differences in AF-related outcomes, such as stroke and bleeding.7)8) Future research should focus on prospective, multi-center randomized controlled trials to validate these findings in diverse populations. Additionally, more detailed analyses of patient-specific factors, including frailty, concomitant medications, and the suitability of non-pharmacological interventions like LAAO, are needed to refine anticoagulation strategies for the very elderly. Nevertheless, the study underscores the importance of NOACs in achieving a delicate balance between efficacy and safety, particularly in the context of global aging trends and the increasing relevance of non-pharmacological alternatives such as LAAO for those at highest bleeding risk.

Finally, we must remember that oral anticoagulation is but one component of a holistic or integrated care approach to AF management. Adherence with such an approach has been associated with improved clinical outcomes,9) leading to its recommendations in recent Asian guidelines.10)11)