Aspirin, NOACs, warfarin: which is the best choice to tackle cognitive decline in elderly patients? Insights from the GIRAF and ASCEND-Dementia trials presented at the AHA 2021
Year: 2021
Type: article
Abstract: Cognitive impairment is common in older adults and its incidence increases with age.1,2 Nowadays, there is no medical treatment available to prevent dementia and the role of antiaggregation and anticoagulation agents remains debated (Figure 1). The role of antiaggregation and anticoagulation agents in preventing dementia remains debated. NOACs, novel oral anticoagulants (including dabigatran, apixaban, rivaroxaban, and edoxaban). In this context, the results of the prospective randomized multicentre trial ‘coGnitive Impairment Related to AF’ (GIRAF) were presented at the 2021 Scientific Sessions of the American Heart Association (AHA). In this clinical trial, 200 patients ≥70 years old (mean age: 75 years; 60% men) with atrial fibrillation (AF) or atrial flutter and a CHA2DS2-VASc score >1 were randomized to receive dabigatran 110 or 150 mg twice daily or warfarin adjusted to an International Normalized Ratio (INR) of 2 to 3. Patients with valvular heart disease, dementia, recent bleeding, a history of stroke, and active cancer were excluded. The 2-year cognitive evaluation, conducted via a computer-generated neuropsychological exam to evaluate sustained, selective, and divided attention, Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and the Neuropsychological Battery test to assess attention memory, language, and executive functions, was completed by 83 patients in the dabigatran arm and 66 patients in the warfarin arm (time spent in therapeutic range: 69.9%). The trial revealed no significant differences between the two arms in terms of changes in memory, executive function, language, or attention, albeit a significant difference (P = 0.02, favouring warfarin) was noted in the MoCA score. However, warfarin users tended to have more haemorrhagic complications. During the trial, no participant was diagnosed with dementia, highlighting the importance of adequate anticoagulation treatment to decrease cognitive decline in older AF patients. The results of the ASCEND (A Study of Cardiovascular Events in Diabetes) dementia trial were also presented at the AHA. The original study included 15 480 adults (mean age: 63 years; 63% men) with type 2 diabetes and no history of cardiovascular disease or dementia at baseline who were randomized to aspirin 100 mg or placebo (mean follow-up: 7.4 years). The main trial results from ASCEND had shown a reduction in major cardiovascular events with aspirin, counterbalanced by an increase in major bleeding.3,4 The investigators now limited their analysis to the 15 427 participants with no evidence of baseline dementia. Cognitive function tests, conducted over the phone or online, were available for 9015 participants, showing no significant difference between aspirin and placebo in the development of dementia [3.3% vs. 3.7%; Relative Risk (RR) 0.89, 95% confidence interval (CI) 0.75–1.06] or broad dementia (including dementia, cognitive impairment, delirium or confusion, referral to a memory clinic or geriatric psychiatry; 7.1% vs. 7.8% RR: 0.91; 95% CI 0.81–1.02). Of note, cognitive scores were similar between the ASCEND and the ASPREE trials.5 The authors concluded that trials with larger numbers of incident dementia cases are needed to assess whether a benefit in using aspirin in these patients actually exists. Conflict of interest: None declared.
Language: English
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W3217520326