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Use of direct oral anticoagulants in very elderly patients: a case report of apixaban in an ultracentenary patient.

Background Atrial fibrillation (AF) is the most common cardiac arrhythmia. Its incidence rises steadily with each decade. AF is associated with substantial mortality and morbidity, including a five-fold increase in the risk of stroke. Stroke prevention in older AF patients is important as stroke risk rises dramatically with age. Older people with AF do better on OAC. Also, they do better on direct oral anticoagulants (DOACs) rather than on vitamin k antagonist (VKA). In this particular category of patients, balancing risks and benefits of antithrombotic strategies is crucial, because, in parallel, the bleeding risk also increases. Oral anticoagulation represents the cornerstone of treatment to reduce the risk of cardioembolic stroke in patients with atrial fibrillation (class of recommendation I, level of evidence A). Since 2010, the regulatory approval of four DOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) has provided an alternative to the use of warfarin for the prevention of cardioembolic stroke in ‘non valvular atrial fibrillation’ (NVAF). Phase III randomized clinical trials have shown that DOACs have at least equal efficacy, with lower rates of intracranial hemorrhage compared with warfarin. Despite the availability of these safer drug alternatives to warfarin, unfortunately, oral anticoagulation use remains suboptimal in elderly patients with atrial fibrillation.