Atrial fibrillation and oral anticoagulation in older people with frailty: a nationwide primary care electronic health records cohort study

Abstract

Background Atrial fibrillation (AF) is common in older people and is associated with increased stroke risk that may be reduced by oral anticoagulation (OAC). Frailty also increases with increasing age, yet the extent of OAC prescription in older people according to extent of frailty in people with AF is insufficiently described. Methods An electronic health records study of 536,955 patients aged ≥65 years from ResearchOne in England (384 General Practices), over 15.4 months, last follow-up 11th April 2017. OAC prescription for AF with CHA2DS2-Vasc ≥2, adjusted (demographic and treatments) risk of all-cause mortality, and subsequent cerebrovascular disease, bleeding and falls were estimated by electronic frailty index (eFI) category of fit, mild, moderate and severe frailty. Results AF prevalence and mean CHA2DS2-Vasc for those with AF increased with increasing eFI category (fit 2.9%, 2.2; mild 11.2%, 3.2; moderate 22.2%, 4.0; and severe 31.5%, 5.0). For AF with CHA2DS2-Vasc ≥2, OAC prescription was higher for mild (53.2%), moderate (55.6%) and severe (53.4%) eFI categories than fit (41.7%). In those with AF and eligible for OAC, frailty was associated with increased risk of death (HR for severe frailty compared with fit 4.09, 95% confidence interval 3.43–4.89), gastrointestinal bleeding (2.17, 1.45–3.25), falls (8.03, 4.60–14.03) and, among women, stroke (3.63, 1.10–12.02). Conclusion Among older people in England, AF and stroke risk increased with increasing degree of frailty; however, OAC prescription approximated 50%. Given competing demands of mortality, morbidity and stroke prevention, greater attention to stratified stroke prevention is needed for this group of the population.

Clinical outcomes in patients with atrial fibrillation and frailty: insights from the ENGAGE AF-TIMI 48 trial

“…One in five participants was frail, and just one in 50 had severe frailty. This is in contrast with the primary care population of older people with AF, in which over half live with moderate or severe frailty [4]. It is known that health problems tend to accumulate with age and therefore frailty is generally progressive [35], with an average rate of deficit accumulation in community-dwelling older people of 3% per year [36].…”

“…Even so, we cannot conclude with certainty from this analysis that the overall trial findings are applicable to patients living with severe frailty. Here, those patients were under-represented, even though they are a group at high risk of stroke, and in whom AF is common [3,4].…”

“…A recent randomised controlled trial found that in older Japanese patients, a daily 15-mg dose of edoxaban was superior to placebo in preventing stroke or systemic embolism, without a significantly higher incidence of major bleeding than placebo [42]. These findings are important, but we know that there is a graded degree of risk amongst older people of the same age [4,7,10,30], and there remains a notable lack of generalisable data concerning the outcomes associated with anticoagulation for patients with more advanced frailty [3]. There are many reasons why older people are historically under-represented in clinical trials, including the presence of co-morbidities, communication issues, and physical immobility that limit opportunities for participation [43].…”

“…Atrial fibrillation (AF) affects at least 10 million people in Europe [1]. The incidence and prevalence of AF increases with age [2] and is more common in patients with frailty [3,4], a condition characterised by a decline in a person's biological reserves and deterioration in physiological mechanisms that render them vulnerable to a range of adverse outcomes [5][6][7][8][9]. Frailty provides an insight into biological age and is more useful than chronological age in predicting adverse events and guiding clinical care [10][11][12][13][14].…”

Prevalence and predictors of subclinical atrial fibrillation in hospitalized older adults

“…Hence, the choice to identify and highlight those patients having a SCAF duration ≥ 6 minutes in our study, in agreement with previous studies [ 35 ], suggesting the possibility to follow these older patients more closely in order to prevent future adverse events. However, the risk of stroke in SCAF and the cost/benefit ratio of anticoagulation is still an open debate, given the lack of agreement in the published literature, especially in older people [ 36 ]. To date, there are no clear parameters of SCAF to initiate oral anticoagulation.…”