When the Time Comes to Stop Oral Anticoagulation: Options and Obstacles

We normally think about a CHA2DS2-VASc score or Watchman Left Atrial Appendage (LAA) procedure. But what about life priorities at a certain age? Or, should it be a combination of all 3 parameters?

https://www.tctmd.com/news/when-time-comes-stop-oral-anticoagulation-options-and-obstacles

Margaret Fang, MD (University of California, San Francisco) said a study led by one of her mentees, Sachin Shah, MD (University of California, San Francisco), provides some data to help inform the issue. Published in 2019, the analysis estimates the net clinical benefit of oral anticoagulation beyond age 75 in patients with AF, showing that the benefits become marginal after age 87 for warfarin and after age 92 for apixaban (Eliquis; Bristol-Myers Squibb).

It's not really surprising, in hindsight, but I would want at least one more comprehensive and largely confirmatory study, a more recent one. But even more, I would wonder at their metrics, especially the assignment of risk. I mean, some 92-year-olds might easily thrive until 98 independently, not in a 'home'. Or to 101. That's a long time hoping the odds don't work against you if your honest-to-goodness CHA2DS2-VASc score isn't diminishing, or if you're still potentially thromboembolic (who past 85 isn't?!?)...AND....still in AF much/all the time.

I mean, some 92-year-olds might easily thrive until 98 independently, not in a 'home'.

Exactly, and at that age, maybe best to continue what is working, and not add more of a stroke risk. Especially since
ACs are not known for side effects. However, what was not mentioned was fall risk, which could argue the other way. Interesting
how the article argues for individualizing anticoagulation treatment over guideline-based, which I firmly believe in, but then
goes on citing a broad guideline-based recommendation about seniors

Jim



Edited 1 time(s). Last edit at 04/03/2026 05:07PM by mjamesone.

For example, when balancing life's priorities, should someone need to take irritating blood thinners when they were in hospice. The article was looking for a balance.

I would say no, not when in hospice, but that's a more personal decision. Hospice means you're definitely not long for this Earth, maybe four weeks tops...typically. So, yeah, in that case, who cares if it's the last agonizing hours of a tumour or your lights go out with a sudden stroke....same diff. Maybe snowed with morphine would be my choice if the former. And no apixaban/rivaroxaban/edoxaban.

If there ever is a real published study that anticoagulants become marginally effective after age 87 for warfarin or age 92 for Eliquis, then it might be a real benefit to already have a Watchman in place (assuming it is still effective) to make up for the anticoagulant loss.

I have parents that lived into their 90's.

I am trained in hospice work and just want to say that the idea that hospice is only for last weeks or even last days, is unfortunate. My mother lived to almost 96, and was on hospice off and on for three years. She remained on Warfarin until the end. Hospice patients can remain on medications not related to their hospice diagnosis. People are missing out on free services such as a daily aide, visiting nurse, hospice MD, social worker, chaplain and volunteer by waiting too long for hospice but feelings about the "h word" re often behind that resistance. "Hospice" means comfort, not necessarily imminent death. Sometimes hospice services improve health and the patient is discharged, at least for awhile.

That's a very good and useful point, Windy. Hospice isn't necessarily 'Stick a fork in me, I'm done.' The concept means a serious attempt to discourage further deterioration and suffering to the extent possible in that facility, so whatever that entails is what is offered to most patients.

Harvard Health says six months or less, but you dear mum is surely representative of another subset.

[www.health.harvard.edu]

Quote
windyshores
I am trained in hospice work and just want to say that the idea that hospice is only for last weeks or even last days, is unfortunate. My mother lived to almost 96, and was on hospice off and on for three years. She remained on Warfarin until the end. Hospice patients can remain on medications not related to their hospice diagnosis. People are missing out on free services such as a daily aide, visiting nurse, hospice MD, social worker, chaplain and volunteer by waiting too long for hospice but feelings about the "h word" re often behind that resistance. "Hospice" means comfort, not necessarily imminent death. Sometimes hospice services improve health and the patient is discharged, at least for awhile.

Yes, I had a grandmother who was on hospice from 99 to 103, while her daughter, my mother, was on it for an hour or two. I have an adult son, who was on it for 5 years and has been off now for 2 (and has a brain cancer diagnosis where the neurosurgeon said the life expectancy is 12-18 months at diagnosis and 2% survive to 5 years - he's been diagnosed for nearly 9). The US Veterans Administration will pay for treating care on hospice, unlike some other agencies. My mother's doc used to tell me about the "hospice effect," where patients felt a lot better when they were taken off their treating meds.