Efficacy and safety of oral anticoagulant therapy in frail patients with atrial fibrillation

Patti, Giuseppe; Mantione, Ludmilla; Bressi, Edoardo; Bisignani, Antonio

doi:10.4081/monaldi.2018.958

Cited by 5 publications

(3 citation statements)

References 11 publications

(17 reference statements)

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“…Underuse of OACs is almost never ascribable to a single geriatric condition or factor, but rather to a combination of barriers [34]. We generally agree with the opinion expressed by Pati and colleagues, that despite that logical considerations and evidence-base data related to the reduced bleeding risk of NOACs make these drugs the anticoagulant agents of choice in frail patients, in the setting of the frail older patients an individualized approach should be taken, taking into consideration the risk of thromboembolic and bleeding events, other comorbidities and patient-related factors, rather than a generalized "one drug fits all" approach [35]. Also each NOAC comes with its own unique advantages and safety profile, so a personalized case by case approach should be adopted to decide on the appropriate anticoagulation regimen for older patients after weighing the overall risks and benefits of therapy [36,37].…”

Section: Discussionsupporting

confidence: 75%

Determinants of anticoagulant therapy in atrial fibrillation at discharge from a geriatric ward: cross sectional study

Wojszel

Kasiukiewicz

2019

J Thromb Thrombolysis

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Oral anticoagulants (OACs) are effective in preventing stroke in older people with atrial fibrillation (AF), but they are often underused in this particularly high-risk population. The aim of the study was to identify health and functional determinants of oral anticoagulant therapy (OA) in AF at discharge from a geriatric sub-acute ward. A cross-sectional study was conducted and patients who presented with atrial fibrillation were analyzed. They were interviewed, examined, assessed with comprehensive geriatric assessment protocol, and had their hospital records analyzed. Relative risks for OA were counted and multivariable logistic regression model was built. 95 patients took part in the study (22.8% of 416 consecutively admitted to the department, 31.9% men, 73.7% 80 + year-old). 25.8% of them were on antiplatelet drugs and 58.9% on OACs. The percentage on OACs increased significantly to 73.7% at discharge (p = 0.004), mainly due to the new OACs prescription (from 11.8 to 33.3%; p < 0.001). Severe frailty (7 point Clinical Frailty Scale ≥ 6) and anemia presence, but not the risk of bleeding according to the HAS-BLED score, significantly decreased the probability of OACs prescription at discharge. There was also a trend for an association of OACs prescription with the higher total score of CHA2DS2-VASc scale. We conclude that in the real-life population of patients with AF comprehensive geriatric assessment might allow to increase significantly the number of patients on OACs, but it is limited by patient's frailty status and anemia diagnosis.

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Section: Discussionsupporting

confidence: 75%

Determinants of anticoagulant therapy in atrial fibrillation at discharge from a geriatric ward: cross sectional study

Wojszel

Kasiukiewicz

2019

J Thromb Thrombolysis

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“…This high prevalence is in line with other studies assessing the prescription of OAC in AF patients in Europe at the time of our study. 36 Although DOACs with their better risk/benefit ratio seem preferable in frail patients, 37 in our study frail patients were more likely to receive VKA. This finding may partly be explained by a physician preference for close INR monitoring, especially in elderly or frail AF patients.…”

Section: Discussioncontrasting

confidence: 48%

Frailty to predict unplanned hospitalization, stroke, bleeding, and death in atrial fibrillation

Gugganig

Aeschbacher

Leong

et al. 2020

European Heart Journal - Quality of Care and Clinical Outcomes

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Aims Atrial fibrillation (AF) and frailty are common, and the prevalence is expected to rise further. We aimed to investigate the prevalence of frailty and the ability of a frailty index (FI) to predict unplanned hospitalizations, stroke, bleeding, and death in patients with AF. Methods and results Patients with known AF were enrolled in a prospective cohort study in Switzerland. Information on medical history, lifestyle factors, and clinical measurements were obtained. The primary outcome was unplanned hospitalization; secondary outcomes were all-cause mortality, bleeding, and stroke. The FI was measured using a cumulative deficit approach, constructed according to previously published criteria and divided into three groups (non-frail, pre-frail, and frail). The association between frailty and outcomes was assessed using multivariable-adjusted Cox regression models. Of the 2369 included patients, prevalence of pre-frailty and frailty was 60.7% and 10.6%, respectively. Pre-frailty and frailty were associated with a higher risk of unplanned hospitalizations [adjusted hazard ratio (aHR) 1.82, 95% confidence interval (CI) 1.49–2.22; P < 0.001; and aHR 3.59, 95% CI 2.78–4.63, P < 0.001], all-cause mortality (aHR 5.07, 95% CI 2.43–10.59; P < 0.001; and aHR 16.72, 95% CI 7.75–36.05; P < 0.001), and bleeding (aHR 1.53, 95% CI 1.11–2.13; P = 0.01; and aHR 2.46, 95% CI 1.61–3.77; P < 0.001). Frailty, but not pre-frailty, was associated with a higher risk of stroke (aHR 3.29, 95% CI 1.2–8.39; P = 0.01). Conclusion Over two-thirds of patients with AF are pre-frail or frail. These patients have a high risk for unplanned hospitalizations and other adverse events. These findings emphasize the need to carefully evaluate these patients. However, whether screening for pre-frailty and frailty and targeted prevention strategies improve outcomes needs to be shown in future studies. Clinical trial registration Clinicaltrials.gov identifier number: NCT02105844.

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“…About 57% were diagnosed as fragile patients; 29% were pre-fragile; and 8% of the studied population was >85 years old, which had a higher number of comorbidities and higher rate of drug use, data that reached statistical significance [44].…”

Section: Fragility and Anticoagulationmentioning

confidence: 88%

Use of Non-Vitamin K-Dependent Oral Anticoagulants in Elderly and Fragile Patients with Atrial Fibrillation

Víctor¹

2022

Anticoagulation - Current Perspectives

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Atrial fibrillation is a frequently observed entity in medical practice, with cases on the rise if we focus on age groups of frail elderly patients. It is important to identify them since advanced age and comorbidities suppose greater numbers of cases of thromboembolic diseases and strokes, entities that can be prevented with the non-vitamin K antagonist oral anticoagulants (NOACs), managing a balance between prevention and safety and thus avoiding complications, for this, a correct search and screening must be made to reach the largest number of patients who could benefit from this therapy. Old age is not a synonym of frailty, so, we must be cautious with the loss of autonomy of our patients and we must have a multidisciplinary approach to accompany this increasingly frequent and extended period, being very alert to drug interactions and decreased daily life skills.

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Efficacy and safety of oral anticoagulant therapy in frail patients with atrial fibrillation

Cited by 5 publications

References 11 publications

Determinants of anticoagulant therapy in atrial fibrillation at discharge from a geriatric ward: cross sectional study

Determinants of anticoagulant therapy in atrial fibrillation at discharge from a geriatric ward: cross sectional study

Frailty to predict unplanned hospitalization, stroke, bleeding, and death in atrial fibrillation

Use of Non-Vitamin K-Dependent Oral Anticoagulants in Elderly and Fragile Patients with Atrial Fibrillation

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