Physicians' Academy for Cardiovascular Education

DOACs and warfarin beneficial for older AF patients according to FORTA classification

Appropriateness of Oral Anticoagulants for the Long-Term Treatment of Atrial Fibrillation in Older People: Results of an Evidence-Based Review and International Consensus Validation Process (OAC-FORTA 2016)

Literature - Wehling M, Collins R, Gil VM, et al. - Drugs Aging. 2017; published online ahead of print


The prevalence of atrial fibrillation (AF) rises with age and anticoagulants are most often used in older AF patients [1]. However, it is not clear whether long-term anticoagulation treatment for AF patients at older ages is appropriate [2,3].

The Fit-fOR-The-Aged (FORTA) classification is based on benefit, risk and appropriateness of drugs for older patients in everyday clinical settings [4,5]. In the randomized controlled trial VALFORTA, FORTA significantly improved medication quality, as measured by FORTA score that adds over- and undertreatment errors, and it reduced adverse drug effects at a number needed to treat of only five [6]. Categories include: Forta-A - highly beneficial, FORTA-B - beneficial, FORTA-C - questionable and FORTA-D - don’t.

In this analysis, the FORTA classification was used to classify eight anticoagulants (vitamin K antagonists [VKA] acenocoumarol, fluindione, phenprocoumon, warfarin and DOACs apixaban, dabigatran, edoxaban and rivaroxaban) as appropriate or inappropriate drugs to prevent stroke in older AF patients, based on efficacy, safety and tolerability. This was based on a structured comprehensive literature review and a subsequent two-step assessment approach.

Main results


All DOACs and warfarin were classified as beneficial or very beneficial in older AF patients (FORTA-A or -B), underlining the overall positive assessment of the risk-benefit ratio for these drugs based on available evidence. For other VKAs (FORTA-C) regionally used in Europe, the lack of evidence should challenge current practice.


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