Impact of Frailty on Bleeding Events Related to Anticoagulation Therapy in Patients With Atrial Fibrillation

Abstract

Background: Although anticoagulation is the key treatment to prevent stroke in patients with atrial fibrillation (AF), including elderly patients, anticoagulation is sometimes withheld for elderly people because of concerns about frailty. However, it remains unknown whether frailty increases bleeding events. Methods and Results: A total of 120 consecutive non-valvular AF patients admitted with symptoms of AF or congestive heart failure were included in this study. Frailty was assessed using the Cardiovascular Health Study (CHS) frailty index. We performed a retrospective analysis of the risk factors associated with major bleeding events. After a median follow-up of 518 days, major bleeding events occurred in 17 (14.2%) patients. Patients with major bleeding events had a higher CHS frailty index (P=0.015). The cutoff value for high-risk CHS frailty index was 2 (area under the ROC curve: 0.68 [95% confidence interval (CI): 0.57-0.78]). The event-free rates at 2 years were 97.6% (95% CI: 83.9-99.7) in patients with a CHS frailty index <2 and 59.6% (95% CI: 27.9-81.0) for those with a CHS frailty index ≥2 (P<0.001). Conclusions: Frailty is associated with increased bleeding events related to anticoagulant therapy in patients previously hospitalized with AF. Greater care should be taken with patients with a CHS frailty index ≥2.

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

“…Indeed, with the progressive aging of the AF population, a significant proportion of patients are burdened by concomitant comorbidities and conditions that increase both thromboembolic and bleeding risks, entailing the so-called "clinical complexity" that influences treatment choices and poses significant challenges in the management of AF. 11 Frailty, chronic kidney disease (CKD), and history of bleeding represent three of the most common conditions that are known to increase the risk of adverse outcomes (including bleeding) in AF patients, [12][13][14][15][16] and are often perceived as major barriers to OAC prescription. 17 Furthermore, these conditions often coexist, leading to further challenges in the management of these patients.…”

Frailty and subsequent adverse outcomes in older patients with atrial fibrillation treated with oral anticoagulants: The Shizuoka study

“…We identified a considerable association between frailty and increased risk of bleeding. A higher risk of bleeding among frail patients with AF has been a concern when initiating OAC [ 21 , 22 ], and previous studies have reported a positive association between frailty and bleeding among patients with AF. This association has been most evident in observational, real-world studies [ 12 , 13 , 22 , 23 ].…”

Clinical Characteristics, Outcomes, and Risk Factors for Adverse Events in Elderly and Non-Elderly Japanese Patients With Non-Valvular Atrial Fibrillation ― Competing Risk Analysis From the Hokuriku-Plus AF Registry ―

“… 34 From our results, the impact of the HAS-BLED score on the prediction of bleeding was different in the elderly and non-elderly AF populations. The elderly population has many clinical problems, such as polypharmacy, 35 frailty, 14 and multimorbidity, 36 which have been reported to be associated with bleeding events and are not included in the HAS-BLED score. This may be the reason for the difference in the impact of the HAS-BLED score between the younger and elderly AF populations.…”

“… 10 However, the use of anticoagulants in elderly patients with non-valvular AF (NVAF) raises concerns about adverse events such as bleeding, because these patients may have bleeding risk factors, including low body weight, susceptibility to falls, renal dysfunction, polypharmacy, and cognitive dysfunction. 11 – 14 …”