Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 592

Bleeding risk is the antithrombotic treatment most important complication, so this requires us to personalize decision‐making, especially in elderly patients with multimorbidity, geriatric syndromes, frailty, or disability. Due to the higher prevalence of comorbid diseases, drug interactions, and age‐related conditions, the risk of anticoagulation‐related major and clinically relevant non‐major bleeding is increased in patients 65 and older versus younger patients. Schulman has comprehensively summarized the increasing body of evidence indicating that age is an independent risk factor for major bleeding in patients receiving oral anticoagulant therapy, with an average twofold increase.²⁴

Increased age also appears to be a risk factor specifically for intracranial haemorrhage. Age ≥75 is associated with at least a two‐fold increase in intracranial haemorrhage risk due to high‐risk conditions such as cerebral amyloid microangiopathy and leukoaraiosis.^25,26

Several scores were developed to help measure bleeding risk in AF²⁷, with no intention of contraindicating oral anticoagulation but rather to modify it with our intervention to increase the anticoagulation therapy’s security profile. The most widespread is the HAS‐BLED score, which includes different determinants, all of which can be modified except age. Other scores, like HEMORR2AGES, add aspects that are included in the Comprehensive Geriatric Assessment (CGA), such as falls and cognitive impairment, which are usually assessed and managed by a geriatrician. The ATRIA Bleeding Risk Score takes into account five parameters and stratifies the bleeding risk into three levels.^28,29 The ORBIT risk score proposes five determinants: age, anaemia, previous bleeding episodes, renal impairment, and antiplatelet therapy. It demonstrates similar discrimination with better sizing than HAS‐BLED and ATRIA scores, according to the ROCKET‐AF trial.³⁰ The ABC‐bleeding score includes age, previous bleeding episodes, and three serum biomarkers (haemoglobin, troponin T, and GDF‐15 or cystatin C/creatinine clearance) and obtains more appropriate results than HAS‐BLED and ORBIT, according to the ARISTOTLE and RE‐LY trials²⁸; but the biomarkers are not standardized, and there is no defined cut‐off point (class IIb indication) (Table 25.1). The results of a recent study suggest that the bleeding risk assessment tools with high sensitivity should be used for AF patients at high risk of bleeding, and bleeding risk assessment tools with high specificity should be used for patients at low risk of bleeding.³¹