Impact of Combined Anticoagulant and Antiplatelet Therapy in Older Patients With Atrial Fibrillation: ANAFIE Subanalysis

Background: We aimed to evaluate the impact of concomitant use of oral anticoagulants (OAC) and antiplatelet drugs (APD) on clinical outcomes compared with OAC monotherapy in patients aged ≥75 years with atrial fibrillation. Methods: The ANAFIE (All Nippon AF [Atrial Fibrillation] in Elderly) Registry was a prospective multicenter observational study in Japan. This subanalysis included patients aged ≥75 years with nonvalvular atrial fibrillation receiving OAC. Patients were classified into OAC monotherapy and concomitant OAC+APD therapy groups. Clinical outcomes, including stroke/systemic embolism, major bleeding, and all-cause mortality, were compared using Cox proportional hazards models. Within the OAC+APD group, outcomes were also compared between patients using direct OACs and those using warfarin. Results: Among 29 818 patients (median age 81 years, 42.3% female), 4861 (16.3%) received OAC+APD therapy. This group had higher proportion of men, previous cerebrovascular disease, and previous myocardial infarction. The group showed increased risk of cardiovascular death [1.57 versus 0.94/100 person-years, adjusted hazard ratio (aHR), 1.29 [95% CI, 1.01-1.64]. There were no significant differences in stroke/systemic embolism, major bleeding, or all-cause mortality. Within the OAC+APD group, direct OAC use was associated with lower risks of stroke/systemic embolism (aHR, 0.55 [95% CI, 0.38-0.80]), intracranial hemorrhage (aHR, 0.52 [95% CI, 0.30-0.90]), and all-cause mortality (aHR, 0.73 [95% CI, 0.58-0.91]) compared with warfarin. Conclusions: In older patients with atrial fibrillation, OAC+APD therapy was associated with higher incidence of cardiovascular death than OAC monotherapy, without significant differences in other clinical outcomes. For patients requiring combination therapy, DOACs may be preferable to warfarin.