Perceived vs. objective frailty in patients with atrial fibrillation and impact on anticoagulant dosing: an ETNA-AF-Europe sub-analysis

Diemberger, Igor; Fumagalli, Stefano; Mazzone, A.; Bakhai, Ameet; Reimitz, Paul-Egbert; Pecen, Ladislav; Manu, Marius Constantin; Souza, José Antonio Gordillo de; Kirchhof, Paulus; Caterina, Raffaele De

doi:10.1093/europace/euac004

Cited by 22 publications

(17 citation statements)

References 20 publications

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“…Negative perceptions linked to the term "frail" have been previously described and are associated with administrations of treatments that do not follow standard of care. 51,52 It is therefore possible the observed risk of stroke could be due to less intensive prevention efforts in these patients. We would like to note that genetic analysis overcomes these limitations of observational studies.…”

Section: Discussionmentioning

confidence: 99%

Higher Hospital Frailty Risk Score Is Associated With Increased Risk of Stroke: Observational and Genetic Analyses

Renedo

Acosta

Koo

et al. 2023

Stroke

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Background: Frailty is a prevalent state associated with several aging-related traits and conditions. The relationship between frailty and stroke remains understudied. Here we aim to investigate whether the hospital frailty risk score (HFRS) is associated with the risk of stroke and determine whether a significant association between genetically determined frailty and stroke exists. Design: Observational study using data from All of Us research program and Mendelian Randomization analyses. Methods: Participants from All of Us with available electronic health records were selected for analysis. All of Us began national enrollment in 2018 and is expected to continue for at least 10 years. All of Us is recruiting members of groups that have traditionally been underrepresented in research. All participants provided informed consent at the time of enrollment, and the date of consent was recorded for each participant. Incident stroke was defined as stroke event happening on or after the date of consent to the All of Us study HFRS was measured with a 3-year look-back period before the date of consent for stroke risk. The HFRS was stratified into 4 categories: no-frailty (HFRS=0), low (HFRS ≥1 and <5), intermediate (≥5 and <15), and high (HFRS ≥15). Last, we implemented Mendelian Randomization analyses to evaluate whether genetically determined frailty is associated with stroke risk. Results: Two hundred fifty-three thousand two hundred twenty-six participants were at risk of stroke. In multivariable analyses, frailty status was significantly associated with risk of any (ischemic or hemorrhagic) stroke following a dose-response way: not-frail versus low HFRS (HR, 4.9 [CI, 3.5–6.8]; P <0.001), not-frail versus intermediate HFRS (HR, 11.4 [CI, 8.3–15.7]; P <0.001) and not-frail versus high HFRS (HR, 42.8 [CI, 31.2–58.6]; P <0.001). We found similar associations when evaluating ischemic and hemorrhagic stroke separately ( P value for all comparisons <0.05). Mendelian Randomization confirmed this association by indicating that genetically determined frailty was independently associated with risk of any stroke (OR, 1.45 [95% CI, 1.15–1.84]; P =0.002). Conclusions: Frailty, based on the HFRS was associated with higher risk of any stroke. Mendelian Randomization analyses confirmed this association providing evidence to support a causal relationship.

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Section: Discussionmentioning

confidence: 99%

Higher Hospital Frailty Risk Score Is Associated With Increased Risk of Stroke: Observational and Genetic Analyses

Renedo

Acosta

Koo

et al. 2023

Stroke

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“…As described previously, 22 each of the 109 frailty-related International Classification of Diseases, Tenth Revision, codes were assigned a weight ranging from 0.1 to 7.1, depending on its strength of the association with frailty (see the definition of HFRS in Table S1). The HFRS was calculated by summing all weighted points from each code, and the cohort was categorized into low (<5), intermediate (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15), and high (>15) risk of frailty. 22 To study a cohort of frail patients with AF, we excluded patients with low frailty risk and patients <50 years of age at AF diagnosis and patients with valvular AF (mechanical heart valves or rheumatic/nonrheumatic mitral stenosis).…”

Section: Study Population and Definition Of Frailtymentioning

confidence: 99%

“…9 Physician concerns regarding cognitive impairment, tendency to fall, and polypharmacy may be influential for withholding OAC therapy. 7,10 The treatment decision is further challenged by lack of adequate evidence for the net clinical benefit (NCB) of OAC in frail patients with AF, who have been underrepresented in the randomized trials. Observational studies have demonstrated an NCB in favor of OAC even in octogenarians 11–13 but at the same time indicate that the NCB diminishes with advancing age.…”

mentioning

confidence: 99%

Net Clinical Benefit of Oral Anticoagulation Among Frail Patients With Atrial Fibrillation: Nationwide Cohort Study

Søgaard,

Jensen,

Højen

et al. 2024

Stroke

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BACKGROUND: Frail people with atrial fibrillation are often undertreated with oral anticoagulants (OACs), and evidence for the net clinical benefit (NCB) of OAC is sparse. We, therefore, examined the risk of thromboembolic events, major bleeding, and NCB of anticoagulation treatment. METHODS: This was a nationwide cohort study including frail patients aged with incident atrial fibrillation between 2013 and 2018. Patients were categorized according to OAC treatment exposure. One-year risks of thromboembolic events and major bleeding were ascertained where death was treated as a competing risk. The NCB of anticoagulation was assessed by a bivariate trade-off between thromboembolism and bleeding. RESULTS: We identified 36 223 frail patients with atrial fibrillation (median age, 79 years; 50.5% female), of whom 61.8% started OAC therapy, while 38.2% were untreated despite indication for stroke prevention. At 1 year, the risk of thromboembolic events was 2.1% (95% CI, 1.8%–2.3%) among patients not receiving OAC versus 1.5% (95% CI, 1.4%–1.7%) in patients with OAC. The bleeding risk was 3.2% (95% CI, 2.9%–3.5%) among patients without OAC versus 3.5% (95% CI, 3.2%–3.8%) among anticoagulated patients. The NCB was 0.70% (95% CI, 0.32%–1.08%), suggesting a benefit of OAC treatment; however, the NCB declined with age and increasing frailty and was lowest among patients >75 years of age or with high frailty level. CONCLUSIONS: Frail patients with atrial fibrillation are often untreated with OAC in routine clinical care despite an indication for stroke prevention. The NCB balancing thromboembolic events and major bleeding was in favor of anticoagulation but decreased with advancing age and increasing frailty.

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“…Third, atrial brillation, a comorbidity on admission, emerged as an associated factor for longer hospital stay in patients undergoing TKA. In a previous study, multivariate analysis of the length of hospital stay in patients with comorbid atrial brillation reported acute coronary syndrome, acute decompensated heart failure, infection, heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection function (HFpEF), elevated N-terminal (NT)-pro hormone brain natriuretic peptide (NT-proBNP) levels, and elevated combination of hypertension, abnormal liver/renal function, stroke history, bleeding history or predisposition, labile international normalized ratio, old age and drug/alcohol usage (HAS-BLED) as predictors of longer hospital stay 25 . In addition, frailty is common in patients with atrial brillation, which possibly impacts therapies and outcomes 26,27 .…”

Section: Related Factors Affecting the Length Of Hospital Staymentioning

confidence: 99%

Factors affecting the length of hospital stay for total knee arthroplasty: a retrospective database study using Diagnosis Procedure Combination

Hara

Kanda

Kobayashi

et al. 2023

Preprint

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This retrospective observational study on the length of stay for total knee arthroplasty was conducted at our institution to determine the impact of relevant factors from the Diagnosis Procedure Combination data. The study cohort included 5831 patients who had osteoarthritis of the knee and had undergone total knee replacement from February 2018 to October 2022 in 38 hospitals. Multivariate analysis showed that factors influencing length of stay include: age (p < 0.001), height (p < 0.001), weight (p = 0.049), body mass index (p = 0.008), Barthel index (p < 0.001), method of anesthesia (p < 0.001), bone transplant (p = 0.010), timing of postoperative rehabilitation (p < 0.001), atrial fibrillation (p < 0.001), chronic pain (p < 0.001) and the number of institutionally treated cases (p < 0.001) (r = 0.451, p < 0.001). Shorter or longer hospital stays were found to be associated with patients' backgrounds and facility factors, which can lead to more accurate estimates of the length of stay and appropriate allocation of resources.

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Perceived vs. objective frailty in patients with atrial fibrillation and impact on anticoagulant dosing: an ETNA-AF-Europe sub-analysis

Cited by 22 publications

References 20 publications

Higher Hospital Frailty Risk Score Is Associated With Increased Risk of Stroke: Observational and Genetic Analyses

Higher Hospital Frailty Risk Score Is Associated With Increased Risk of Stroke: Observational and Genetic Analyses

Net Clinical Benefit of Oral Anticoagulation Among Frail Patients With Atrial Fibrillation: Nationwide Cohort Study

Factors affecting the length of hospital stay for total knee arthroplasty: a retrospective database study using Diagnosis Procedure Combination

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