Treatment of venous thromboembolism in elderly patients in the era of direct oral anticoagulants

The incidence of venous thromboembolism (VTE) and VTE-related morbidity and mortality increase with advancing age. Over the past decade, substantial advances in the treatment of VTE have been achieved. Most notably, direct oral anticoagulants (DOACs) were introduced, which offer simple treatment regi- mens across a broad spectrum of patients with VTE and have become the first-choice anticoagulants in many individuals in this population. Even though elderly patients are underrepresented in clinical trials, the extrapolation of overall study results to the elderly subpopulation can be considered justified regarding acute VTE treatment and the choice of anticoagulant agent. In the elderly, DOACs are not only associated with a lower bleeding risk but they also appear to be even more efficacious than vitamin K antagonists in preventing recurrent VTE during the acute treatment period. Determining the optimal treatment duration is the most challenging aspect of VTE management in elderly patients. The risk of bleeding increases with advancing age, and several risk factors for recurrent VTE after stopping anticoagulation are also more frequent in the elderly. Clinical decision rules estimating the risk of recurrent VTE and bleeding have limited utility in elderly patients. Shared decision making considering patients' preferences and values is therefore crucial to help determine individual treatment duration in these patients.