COVID-19 and Atrial Fibrillation in Older Patients: Does Oral Anticoagulant Therapy Provide a Survival Benefit?—An Insight from the GeroCovid Registry

Abstract

Introduction. Atrial fibrillation (AF), the most frequent arrhythmia of older patients, associates with serious thrombo-embolic complications and high mortality. COVID-19 severely affects aged subjects, determining an important prothrombotic status. Aim of this study was to evaluate mortality-related factors in older AF patients with COVID-19. Methods. Between March and June 2020, we enrolled >=60 years in-hospital COVID-19 patients (N=806) in GeroCovid, a multicenter observational study promoted by the Italian Society of Gerontology and Geriatric Medicine. Results. The prevalence of AF was 21.8%. In-hospital mortality was higher in the AF group (36.9 vs. 27.5%, p=0.015). At admission, 51.7%, 10.2% and 38.1% of AF cases were taking, respectively, oral anticoagulants (OACs), antiplatelet agents and no antithrombotic therapy. During hospitalization, 51% patients switched to low-molecular weight heparins. AF patients who survived were younger (81±8 vs. 84±7 years; p=0.002) and had a lower CHA2DS2-VASc score (3.9±1.6 vs. 4.4±1.3; p=0.02) than those who died. OACs use before (63.1% vs. 32.3%; p<0.001) and during hospitalization (34.0% vs. 12.7%; p=0.002) was higher among survivors. At multivariable analysis, lower age, higher self-sufficiency, less severe initial COVID-19 presentation, and the use of Vitamin K antagonists (OR=0.16, 95%CI: 0.03-0.84) or DOACs (OR=0.22, 95%CI: 0.08-0.56) at admission, or the persistence of OAC during hospitalization (OR=0.05, 95%CI: 0.01-0.24), were associated with a lower chance of in-hospital death. Conclusions. AF is a prevalent and severe condition in older COVID-19 patients. Advanced age, dependency and relevant clinical manifestations of disease characterized a worse prognosis. Pre-admission and in-hospital anticoagulant therapy were positively associated with survival.

Atrial fibrillation and COVID-19 in older patients: how disability contributes to shape the risk profile. An analysis of the GeroCovid registry

“…In GeroCovid, no differences in COVID-19 disease severity at admission were observed by arrhythmia status. However, as mentioned above, AF patients presented a higher degree of functional dependency, with this factor being significantly associated with mortality and further strengthened by the lack of use of oral anticoagulants [ 10 ]. Indeed, some population studies found that the years lived with disability and the disability-adjusted life years are progressively increasing when AF is present, with a trend closely mirroring the prevalence of the arrhythmia [ 21 ].…”

“…For the purpose of the study, given the distribution of the variable in our population, we categorized patients as without vs. with functional limitations, by grouping levels 1 and 2 (the patient can walk independently or with a cane) and levels 3–7 (the patient can walk using a walker; the patient can move around with a wheelchair; the patient does not move around but he is accompanied outside on the wheelchair; the patient is confined at home, mostly lying on the bed; the patient does not autonomously stand up or get in sitting position) [ 10 ]. According to the World Health Organization (WHO) classification and on patients’ distribution, the baseline severity of COVID-19 was defined as mild with no oxygen support needed, mild with low-flow oxygen support needed, and severe or critical (high-flow oxygen support required, need of non-invasive or invasive mechanical ventilation, or organ support) [ 10 ]. Finally, data on in-hospital mortality were also recorded for all the study participants.…”

“…In a polycentric Italian experience, including a population ≥ 18 years, the arrhythmia (in clinical history or new-onset) was associated with all-cause mortality in hospitalized patients, independently of older age [ 9 ]. Lastly, in a previous analysis of the GeroCovid registry, we observed that the use of oral anticoagulation prior to the hospitalization for SARS-CoV-2 infection positively correlated with survival in aged AF individuals [ 10 ], evidence not found in a younger population [ 8 ]. On this basis, we planned a comprehensive assessment of the clinical characteristics and risk profile of older COVID-19 patients with and without AF in order to define whether and, possibly, through which mechanisms, AF and age could interact affecting in-hospital survival.…”

Thrombosis and Haemostasis 2021 Editors' Choice Papers

“…17,18 The multicenter observational GeroCovid study, presented convincing data on the role of direct oral anticoagulants (DOACs) in reducing the risk of death in COVID-19 older patients. 19 While the beneficial anticoagulation effects of heparin on the thrombotic arm of COVID-19 is easily explicable, intriguing data from Mycroft-West et al suggested that heparin may also prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from infecting cells, 20 opening options for repurposing heparin and its derivatives as antiviral agents.…”

Risk of Thrombotic Events and Other Complications in Anticoagulant Users Infected With SARS-CoV-2: An Observational Cohort Study in Primary Health Care in SIDIAP (Catalonia, Spain)

“…5,14 Most studies are focused on analyzing the risk of thromboembolic events and complications from the COVID-19 infection in patients on anticoagulant treatment once hospitalized. [15][16][17]…”