Impact of frailty on early rhythm control outcomes in older adults with atrial fibrillation: A nationwide cohort study

Abstract

PurposeRhythm-control therapy administered early following the initial diagnosis of atrial fibrillation (AF) has superior cardiovascular outcomes compared to rate-control therapy. Frailty is a key factor in identifying older patients’ potential for improvement after rhythm-control therapy. This study evaluated whether frailty affects the outcome of early rhythm-control therapy in older patients with AF.MethodsFrom the Korean National Health Insurance Service database (2005–2015), we collected 20,611 populations aged ≥65 years undergoing rhythm- or rate-control therapy initiated within 1 year of AF diagnosis. Participants were emulated by the EAST-AFNET4 trial, and stratified into non-frail, moderately frail, and highly frail groups based on the hospital frailty risk score (HFRS). A composite outcome of cardiovascular-related mortality, myocardial infarction, hospitalization for heart failure, and ischemic stroke was compared between rhythm- and rate-control.ResultsEarly rhythm-control strategy showed a 14% lower risk of the primary composite outcome in the non-frail group [weighted incidence 7.3 vs. 8.6 per 100 person-years; hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.79–0.93, p < 0.001] than rate-control strategy. A consistent trend toward a lower risk of early rhythm-control was observed in the moderately frail (HR 0.91, 95% CI 0.81–1.02, p = 0.09) and highly frail (HR 0.93, 95% CI 0.75–1.17, p = 0.55) groups.ConclusionAlthough the degree attenuated with increasing frailty, the superiority of cardiovascular outcomes of early rhythm-control in AF treatment was maintained without increased risk for safety outcomes. An individualized approach is required on the benefits of early rhythm-control therapy in older patients with AF, regardless of their frailty status.

Assessment and Management of Atrial Fibrillation in Older Adults with Frailty

“…Given the physiologic connections and shared risk factors between AF and frailty, systematic AF screening may be considered for patients with frailty, and frailty testing may be incorporated into the evaluation of older adults with atrial fibrillation [1,2,9,32,35]. The staples of AF medical management-rate control, early rhythm control, and oral anticoagulation-are challenging for patients with frailty due to polypharmacy, multimorbidity, and concern for adverse effects, resulting in under-prescription of indicated medications [2,89,107]. Alternatives such as catheter ablation, percutaneous left atrial appendage occlusion, and low-dose anticoagulation all have limited evidence for frail older adults and merit further study [80,97,105].…”

Atrial fibrillation: comorbidities, lifestyle, and patient factors

“… 259 Also, rhythm-control vs rate-controlled strategy did not significantly reduce a combined cardiovascular outcome in AF patients with moderate-severe frailty. 260 A holistic approach is therefore needed, as promoted by the ABC pathway. 135 Adherence to the ABC pathway reduced the risk of all-cause death by 26%.…”

All-Cause Death and Major Adverse Events in Atrial Fibrillation with Frailty: Observations from the Korea National Health Insurance Service Data

“…However, in frail older patients with AF, this approach may not be helpful because of the high morbidity and mortality. Similarly, the optimal medical treatment for AF in a frail population may differ from that in a non-frail population in terms of polypharmacy, a variety of medications, and doses of medication [ 15 , 16 , 17 ]. According to a recent study, ablation is potentially associated with a decreased risk of mortality and composite outcomes in non-frail older patients with AF.…”

“…Further studies can help provide a clear understanding of the effectiveness of ablation in different patient populations, including frail individuals with AF. Although the degree of benefit decreased as frailty increased, the advantage of implementing early rhythm control strategies in managing AF concerning cardiovascular outcomes was consistent, without an elevated risk of adverse outcomes [ 17 ]. Among frail patients with AF, oral anticoagulant (OAC) treatment has been associated with favorable clinical outcomes.…”

“…Previous evidence suggests that frail patients with AF are more likely to experience adverse events [ 15 , 16 , 17 ]. Therefore, frailty is important for estimating risks and aiding in the diagnosis and care planning of older patients with AF [ 18 ].…”