JSUR Journal

Editorial

Recently, the number of elderly patients under anticoagulant therapy has increased, this is due to the rise in global expectancy of life and cardiological conditions, mainly atrial fibrillation. However, anticoagulant therapy is not risk-free. Bleeding is a serious complication of anticoagulant therapy that lead to high mortality, especially in elderly patients. Moreover, patients with high risk of bleeding are those who will benefit most from anticoagulant drugs [1,2]. The decision of treating elderly patients with these anticoagulant drugs is not easy and different scores have been reported to help the physician. Risk factors include age, creatinine, haemoglobin, platelet count, obesity, hepatic disease etc. Bleeding occurs mainly at intracranial and retroperitoneal levels, both situations can be fatal.

In some occasions conservative treatment: interruption of anticoagulant therapy, fluid therapy and embolisation could be enough, however, in other situations the surgeon will have to face challenging circumstances in a patient that usually have co-morbid factors [3-6].

Retroperitoneal haematomas can be difficult to deal with, the best option is conservative treatment when the situation allows it, but unfortunately unstable patients will need surgery. However, surgery is not always a good solution and the surgeon could only find a large haematoma where only can offer a “packing”. This could place the patient even in a worse situation. On other occasions, haematomas can lead to abdominal compartment syndrome that may also require surgery [7-9]. Similarly, rectus sheath haematomas can be the result of anticoagulant therapy. Most of them are treated successfully with interruption of anticoagulant, fluid therapy or embolisation, but when they fail, surgery is the only option. In this case, the surgeon will find a heterogeneous haematoma and occasionally will be able to locate the active bleeding point, however, this could cause a great damage to the abdominal wall that could worsen the situation [7,8].

In conclusion, anticoagulant therapy in elderly patients can have fatal consequences and surgery is indicated only in those situations where other conservative treatments have failed. It must be taken into account that surgery could cause more damage and not always offers benefit. So, is safe anticoagulant in elderly patients? The answer is not easy. But a careful monitoring of elderly patients is mandatory in order to avoid fatal consequences, Moreover, benefit and risks must be estimated carefully using the different scores. The physician must have in mind the risk of bleeding complications and occasionally the need of surgery to stop the haemorrhage.

Recently, it has been published a lower rate of bleeding complications with oral anticoagulants, however, we will still need more time and studies to determine this.

1.       Zubaid M, Saad H, Ridha M, Mohanan Nair KK, et al. (2013) Quality of anticoagulation with warfarin across Kuwait. Hellenic J Cardiol 54: 102-106.

2.       Pokorney SD, Simon DN, Thomas L, Fonarow GC, Kowey PR, et al. (2015) Patients’ time in therapeutic range on warfarin among US patients with atrial fibrillation: Results from ORBIT-AF registry. Am Heart J 170: 141-148.

3.       Robert-Ebadi H and Righini M (2010) Anticoagulation in the Elderly. Pharmaceuticals 3: 3543-3569.

4.       Wysowski DK, Nourjah P, Swartz L (2007) Bleeding complications with warfarin use: a prevalent adverse effect resulting in regulatory action. Arch Intern Med 167: 1414-1419.

5.       Palareti G, Hirsh J, Legnani C, Manotti C, D'Angelo A, et al. (2000) Oral anticoagulation treatment in the elderly: a nested, prospective, case-control study. Arch. Intern. Med 160: 470-478.

6.       Gage BF, Yan Y, Milligan PE, Waterman AD, Culverhouse R, et al. (2006) Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J 151: 713-719.

7.       Wada Y, Yanagihara C, Nishimura Y (2005) Bilateral Iliopsoas hematomas complicating anticoagulant therapy. Intern Med 44: 641-643.

8.       López-López JA, Sterne JAC, Thom HHZ, Higgins JPT, Hingorani AD, et al. (2017) Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis. BMJ 359.

9.       Fernandes C, Pereira P, Rodrigues M (2015) Spontaneous iliopsoas muscle haematoma as a complication of anticoagulation in acute cerebral venous thrombosis: to stop or not to stop (the anticoagulation)? BMJ Case Rep 2015.