Clinical Complexity Domains, Anticoagulation, and Outcomes in Patients with Atrial Fibrillation: A Report from the GLORIA-AF Registry Phase II and III

Abstract

Background Clinical complexity is common in atrial fibrillation (AF) patients. We assessed the impact of clinical complexity on oral anticoagulant (OAC) treatment patterns and major adverse outcomes in a contemporary cohort of AF patients. Methods The GLORIA-AF Phase II and III Registry enrolled newly diagnosed AF patients with at least one stroke risk factor. Among patients with CHA2DS2-VASc score ≥2, we defined four domains of perceived clinical complexity: frail elderly (age ≥75 years and body mass index <23 kg/m2), chronic kidney disease (CKD, creatinine clearance <60 mL/min), history of bleeding, and those with ≥2 of the above conditions. We evaluated the associations between clinical complexity domains and antithrombotic treatment prescription, risk of OAC discontinuation, and major adverse outcomes. Results Among the 29,625 patients included (mean age 69.6 ± 10.7 years, 44.2% females), 9,504 (32.1%) presented with at least one complexity criterion. Clinical complexity was associated with lower OAC prescription, with stronger associations in frail elderly (odds ratio [OR]: 0.47, 95% confidence interval [CI]: 0.36–0.62) and those with ≥2 complexity domains (OR: 0.50, 95% CI: 0.44–0.57). Risk of OAC discontinuation was higher among frail elderly (hazard ratio [HR]: 1.30, 95% CI: 1.00–1.69), CKD (HR: 1.10, 95% CI: 1.02–1.20), and those with ≥2 complexity domains (HR: 1.39, 95% CI: 1.23–1.57). Clinical complexity was associated with higher risk of the primary outcome of all-cause death, thromboembolism, and major bleeding, with the highest magnitude in those with ≥2 criteria (HR: 1.63, 95% CI: 1.43–1.86). Conclusion In AF patients, clinical complexity influences OAC treatment management, and increases the risk of poor clinical outcomes. These patients require additional efforts, such as integrated care approach, to improve their management and prognosis.

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“…Recent guidelines on HF [5] and AF [6,7] has advocated for the implementation of integrated and holistic care programmes, recognizing the increased clinical complexity that AF and HF patients often experience, and reflecting a paradigm shift towards a more patient-centered approach to the management of these diseases [8,9].…”

A Happy New Year 2023 from Thrombosis and Haemostasis

“…This paper by Romiti et al 17 was also a simultaneous publication at the European Society of Cardiology congress in Barcelona, facilitating publicity and profile for the journal.…”

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“…33,34 In AF, for example, clinical complexity translates to greater risk of adverse clinical outcomes, yet is associated with suboptimal oral anticoagulation prescribing and greater discontinuations. 35 Much interest has focused on the use of biomarkers to refine assessment of stroke and bleeding risks, but challenges remain given that many biomarkers are nonspecific and reflect a sick patient or a sick heart. 36 Venous Thromboembolism in Cancer and in Chronic Kidney Disease Venous thromboembolism (VTE) is a common complication in cancer patients, with a sevenfold increased risk of developing VTE.…”