Anticoagulation in Patients With Atrial Fibrillation Who Are Frail—Toward Better Care

Abstract

With the increasing age and complexity of patients with atrial fibrillation (AF), the role of frailty as a key driver of challenging management and poor prognosis has been increasingly acknowledged.Frailty is a clinical syndrome, defined by reduced physiological reserve and higher susceptibility to stressors, which bolsters the risk of adverse outcomes 1 ; in clinical practice, frailty is entwined with aging and multimorbidity, thus entailing the so-called clinical complexity that often complicates management and prognosis in patients with AF.Current estimates suggest that up to 40% of patients with AF are frail, and previous studies have shown an overall suboptimal use of oral anticoagulant (OAC) in these individuals. 1 Nonetheless, limited data are available on OACs in patients with AF who are frail, particularly regarding comparisons among different OACs: a 2022 Korean nationwide study showed an overall lower risk of adverse outcomes in patients treated with direct OAC (DOAC) compared with warfarin in patients with AF who are frail, 2 while an analysis of Medicare data found that apixaban (but not dabigatran or rivaroxaban) was associated with lower rates of adverse events compared with warfarin among patients who are frail. 3 Notwithstanding this previous evidence, more data, particularly on comparisons among different DOACs, are still needed.This study by Lin and colleagues 4 analyzed Medicare beneficiaries data to compare patients aged 65 years and older with AF who were treated with apixaban, rivaroxaban, or warfarin across frailty status. After propensity score overlap weighting, Lin et al 4 analyzed the association of OACs with different outcomes, including a composite clinical end point of death, thromboembolic events, and major bleeding; health care costs; and the risk of more than 14 days of home time lost, where home time was defined as the number of days in which patients were alive and not in a hospital or skilled nursing facility. During a 1-year follow-up, Lin et al 4 found that apixaban was associated with a lower rate of the clinical composite end point and a lower risk of home time lost compared with rivaroxaban and warfarin; these reductions were greater in patients with AF who were frail compared with patients who were not frail. Apixaban was also associated with lower health care costs compared with rivaroxaban; conversely, lower total costs were observed with warfarin, although different results (ie, lower costs in apixaban users) were observed when excluding the OAC cost.These results expand previous observations and have important clinical implications. Indeed, different from previous studies, Lin et al 4 focused not only on clinical end points but also on the impact of OAC choice on health care costs and, more importantly, on a patient-centered outcome (ie, the risk of home time lost associated with different OACs) that has clear relevance for both patients and their families. The results presented by Lin et al 4 are relevant also considering the strong impact of frailty in determining ...