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Malcolm Man-Son-Hing, MD, MSc, FRCPC; Graham Nichol, MD, MPH, FRCPC; Anita Lau; Andreas Laupacis, MD, MSc, FRCPC

Arch Intern Med. 1999;159:677-685.

Objective  To determine whether the risk of falling (with a possible increased chance of subdural hematoma) should influence the choice of antithrombotic therapy in elderly patients with atrial fibrillation.

Design  A Markov decision analytic model was used to determine the preferred treatment strategy (no antithrombotic therapy, long-term aspirin use, or long-term warfarin use) for patients with atrial fibrillation who are 65 years of age and older, are at risk for falling, and have no other contraindications to antithrombotic therapy. Input data were obtained by systematic review of MEDLINE. Outcomes were expressed as quality-adjusted life-years.

Results  For patients with average risks of stroke and falling, warfarin therapy was associated with 12.90 quality-adjusted life-years per patient; aspirin therapy, 11.17 quality-adjusted life-years; and no antithrombotic therapy, 10.15 quality-adjusted life-years. Sensitivity analysis demonstrated that, regardless of the patients' age or baseline risk of stroke, the risk of falling was not an important factor in determining their optimal antithrombotic therapy.

Conclusions  For elderly patients with atrial fibrillation, the choice of optimal therapy to prevent stroke depends on many clinical factors, especially their baseline risk of stroke. However, patients' propensity to fall is not an important factor in this decision.

From the Department of Medicine, University of Ottawa (Drs Man-Son-Hing, Nichol, and Laupacis), and the Clinical Epidemiology Unit (Drs Man-Son-Hing, Nichol, and Laupacis and Ms Lau) and Geriatric Assessment Unit (Dr Man-Son-Hing), Ottawa Hospital, Ottawa, Ontario. Dr Nichol is a Career Scientist of the Ontario Ministry of Health. Dr Laupacis is a Career Scientist of the Medical Research Council of Canada.

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