Stopping anticoagulation due to high Falls risk


Why this page is important: Some cosdultants are reluctant to prescribe anticoagulants, especially for the very old or frailest patients, as they are perceived to be at higher risk for the consequences of falls such as traumatic brain injury (TBI) Although these consequences are rare, they can have devastating effects and are therefore likely to influence clinical decision making HOWEVER The fear of falls may be overstated, as a patient may need to fall around 300 times per year for the risk of intracranial haemorrhage to outweigh the benefit of oral anticoagulants in stroke prevention.

Prescribing DOACs in patients with a high falls risk

  • Falls should therefore be considered but as part of a full risk/benefit review
  • NICE Guidelines: Do not withhold anticoagulation solely because the person is at risk of having a fall.
  • Remarkably, the bleeding profile of DOACs is more favourable than that of warfarin. This is true in particular for intracranial and other life-threatening haemorrhagic events. Not only is there non-inferiority or even superiority for the overall incidence of bleeding, but the outcome of bleeding complications under NOAC treatment has also been demonstrated to be more benign compared to bleedings that develop during VKA treatment.
  • The benefit from NOAC therapy (best shown for edoxaban and apixaban) is evident also in frail very old patients; thus, frailty and an increased risk of falling per se should not be considered exclusion criteria for anticoagulation


Hanon O, Assayag P, Belmin J, Collet JP, Emeriau JP, Fauchier L, Forette F, Friocourt P, Gentric A, Leclercq C, Komajda M, Le Heuzey JY; French Society of Geriatrics and Gerantology; French Society of Cardiology. Expert consensus of the French Society of Geriatrics and Gerontology and the French Society of Cardiology on the management of atrial fibrillation in elderly people. Arch Cardiovasc Dis. 2013;106:303-23. 

Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Collins R, Camm AJ, Heidbüchel H; ESC Scientific Document Group. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018;39:1330-93. 


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