Oral anticoagulation therapy in nonagenarian patients with atrial fibrillation: usage patterns, predictors, and in-hospital outcomes from a single-center retrospective study

Abstract

Atrial fibrillation (AF) is highly prevalent in nonagenarians (≥ 90 years). However, this group is often excluded from clinical trials, leaving limited real-world evidence on oral anticoagulant (OAC) use, safety, and efficacy. This study sought to investigate the usage patterns, predictors, and in-hospital outcomes of OAC therapy in nonagenarian patients with AF to provide real-world evidence to inform clinical decision-making. A retrospective single-center analysis was conducted on 290 nonagenarian AF patients (Beijing Hospital, 2018–2024). Patients were grouped as OAC ( n  = 89) or non-OAC ( n  = 201). Primary endpoints: In-hospital stroke/SE (efficacy) and major bleeding (ISTH criteria; safety). Secondary endpoints included in-hospital composite efficacy, net clinical benefit (stroke/SE/major bleeding/all-cause death), and all-cause death. Multivariate logistic regression identified OAC predictors; OAC temporal trends were analyzed. The overall OAC utilization rate was 30.69% and showed a steady annual increase. Positive predictors of OAC use included a history of ischemic stroke (OR = 2.653) and heart failure (OR = 2.083), while negative predictors included bedridden status (OR = 0.134), and concomitant antiplatelet use (OR = 0.203). DOAC accounted for 82.02% of OAC prescription, and 63.01% of DOAC users were inappropriately underdosed. Compared with the non-OAC group, OAC use was significantly associated with a lower risk of in-hospital stroke/SE (6.74% vs. 15.42%, OR = 0.396, 95% CI = 0.159–0.987, p  = 0.047) and improved secondary composite efficacy outcomes (OR = 0.491, p  = 0.024). The OAC group also demonstrated a numerically lower incidence of net clinical benefit outcomes (20.22% vs. 30.85%), though it did not differ significantly between groups (2.25% vs. 0.50%, p  = 0.215), though total bleeding events were higher in the OAC group (49.44% vs. 36.32%, p  = 0.037). Although the overall OAC utilization rate in AF patients aged ≥ 90 years remains relatively low, it has shown a steady annual increase, with DOACs emerging as the predominant choice. OAC therapy is significantly associated with a lower risk of in-hospital stroke and demonstrates favorable net clinical benefit, highlighting the potential value of the judicious use of OAC in this population. Chinese Clinical Trial Registry, identifier ChiCTR2300076161.