Presence of Geriatric Conditions Is Prognostic of Major Bleeding in Older Patients with Atrial Fibrillation: a Cohort Study

Background Limited prospective data exist about the clinical relevance of frailty in patients with atrial fibrillation (AF) or venous thromboembolism (VTE) receiving direct oral anticoagulants (DOACs). The aim of this study was to evaluate whether frailty phenotype identifies DOAC‐treated patients at higher risk of adverse clinical outcomes. Methods Consecutive, adult outpatients treated with DOACs for AF or VTE were prospectively enrolled. Patients were classified as frail, pre‐frail, or non‐frail according to frailty phenotype. Study outcomes were clinically relevant bleeding, including major and clinically relevant non‐major bleeding, arterial and venous thromboembolism, and all‐cause mortality. Results 236 patients (median age 78 years, 44% females) were included, of whom 156 (66%) had AF and 80 (34%) VTE. Ninety‐eight (41%) patients were frail, 115 (49%) pre‐frail, and 23 (10%) non‐frail. Inappropriately high or low dose DOAC was used in 33% of frail and in 20% of non‐frail or pre‐frail patients. Over a median follow‐up of 304 days, the incidence of clinically relevant bleeding, thromboembolism, and mortality were 20%, 4%, 9% in frail, and 10%, 3%, and 2% in pre‐frail, respectively, while no study outcome occurred among non‐frail patients. Risk ratios (95% confidence intervals) for these outcomes in frail versus pre‐frail and non‐frail patients were respectively 2.5 (1.8, 3.7), 1.9 (0.9, 4.0), and 6.3 (2.9, 13.6). Conclusion In a prospective cohort of ambulatory patients receiving DOAC treatment for AF or VTE, frailty phenotype identified patients at higher risk of bleeding and all‐cause mortality. Frailty assessment could be valuable to guide targeted interventions potentially improving patient prognosis.

Section: Introductionmentioning

confidence: 89%

Frailty phenotype as a predictor of bleeding and mortality in ambulatory patients receiving direct oral anticoagulants

Candeloro

Nisio

Potere

et al. 2022

“…This is partly because it is unclear how the results of assessment of cognitive function should affect clinical management. We recently reported that cognitive impairment was prospectively associated with bleeding and death but not stroke in older individuals with atrial fibrillation already on anticoagulation 6 . The present study additionally includes individuals not taking anticoagulation and elucidates the role of cognitive function in anticoagulation decision‐making: to prevent one stroke, 3.7 patients would suffer major bleeding and 1.7 would die.…”

Section: Discussionmentioning

confidence: 86%

“…We recently reported that cognitive impairment was prospectively associated with bleeding and death but not stroke in older individuals with atrial fibrillation already on anticoagulation. 6 The present study additionally includes individuals not taking anticoagulation and elucidates the role of cognitive function in anticoagulation decision-making: to prevent one stroke, 3.7 patients would suffer major bleeding and 1.7 would die. These findings are useful in informed decision-making about anticoagulation therapy for older patients with AF and should encourage the assessment of cognitive function in patients with AF.…”

Section: Discussionmentioning

confidence: 99%

“…5 We have reported that in older individuals with AF who are prescribed anticoagulants, frailty and cognitive impairment are associated with increased risk of bleeding and death. 6 In this report, we additionally include individuals not prescribed anticoagulation and examined whether the therapeutic harm associated with anticoagulation differs by cognitive and functional status in older individuals with AF.…”

Section: Introductionmentioning

confidence: 99%

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Differential effect of anticoagulation according to cognitive function and frailty in older patients with atrial fibrillation

Wang

Lessard

Kiefe

et al. 2022

Self Cite

Background In older patients with atrial fibrillation (AF), cognitive impairment and frailty are prevalent. It is unknown whether the risk and benefit of anticoagulation differ by cognitive function and frailty. Methods A total of 1244 individuals with AF with age ≥65 years and a CHADSVASC score ≥2 were recruited from clinics in Massachusetts and Georgia between 2016 and 18 and followed until 2020. At baseline, frailty status and cognitive function were assessed. Hazard ratios of anticoagulation on physician adjudicated outcomes were adjusted by the propensity for receiving anticoagulation and stratified by cognitive function and frailty status. Results The average age was 75.5 (± 7.1) years, 49% were women, and 86% were prescribed oral anticoagulants. At baseline, 528 (42.4%) participants were cognitively impaired and 172 (13.8%) were frail. The adjusted hazard ratios of anticoagulation for the composite of major bleeding or death were 2.23 (95% confidence interval: 1.08–4.61) among cognitively impaired individuals and 0.94 (95% confidence interval: 0.49–1.79) among cognitively intact individuals (P for interaction = 0.08). Adjusted hazard ratios for anticoagulation were 1.84 (95% confidence interval: 0.66–5.13) among frail individuals and 1.39 (95% confidence interval: 0.84–2.40) among not frail individuals (P for interaction = 0.67). Conclusion Compared with no anticoagulation, anticoagulation is associated with more major bleeding episodes and death in older patients with AF who are cognitively impaired.

“…An important limitation of these trials is that older adults with multimorbidity, including cognitive impairment and frailty, were either peremptorily excluded from participation or markedly under-represented. Since older adults with multimorbidity, cognitive impairment or frailty are at increased risk for bleeding complications, 8,9 the balance between benefit and harm of anticoagulation may be altered; as a consequence, the applicability of trial findings to these patients is uncertain.…”

mentioning

confidence: 99%

Anticoagulation for atrial fibrillation: Time to revise the paradigm?

Rich

2022