Atrial Fibrillation, Anticoagulation, and Major Bleeding Episodes in Geriatric Patients at the Risk of Falling

Zwart, L A R; Germans, Tjeerd; Şimşek, Suat; Ruiter, Jaap H.; Jansen, R.W.W.M.

doi:10.21926/obm.geriatr.1903071

Cited by 3 publications

(6 citation statements)

References 25 publications

(37 reference statements)

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“…The index is calculated as the ratio between present items and the total number of items, and ranges from 0 to 1. Patients are considered moderately frail if they have a score of 0.18 or higher and severely frail if they have a score of 0.25 or higher [4,5,22]. The index is designed to contain all factors associated with adverse outcomes such as unplanned hospitalization, major cardiovascular events, and mortality [7,8,11].…”

Section: Methodsmentioning

confidence: 99%

“…In the coming decades, the prevalence of AF among people of 65 years and older is expected to roughly double, mostly with new cases in those aged over 80 years [1]. Patients with AF of 80 years and older form a high-risk group for both stroke and major bleeding [1,2] but also are more likely to be frail [3][4][5]. Frailty is defined as a clinical state in which patients have diminished functionality in different domains, such as physical and cognitive functioning and mobility, leading to a higher risk of adverse outcomes in general [6][7][8].…”

Section: Introductionmentioning

confidence: 99%

“…Based on their definition of being at risk of falls, it is very likely that this sub-group was much frailer than those without a risk of falling [20]. Our recent analysis showed that within a cohort of frail patients, either the use of antiplatelet agents or oral anticoagulation significantly increases the risk of major bleeding [4]. However, despite their frailty, the risk of major bleeding per 100 treatment years of anticoagulation was similar to that in the large RCTs, in which frail patients were underrepresented [4].…”

Section: Introductionmentioning

confidence: 99%

“…Our recent analysis showed that within a cohort of frail patients, either the use of antiplatelet agents or oral anticoagulation significantly increases the risk of major bleeding [4]. However, despite their frailty, the risk of major bleeding per 100 treatment years of anticoagulation was similar to that in the large RCTs, in which frail patients were underrepresented [4]. Whether the use of anticoagulation or antiplatelet agents are independently associated with mortality among frail patients is less clear and is the focus of this analysis [1,19,20].…”

Section: Introductionmentioning

confidence: 99%

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The Use of Oral Anticoagulation Is Not Independently Associated with Mortality in Frail Older Patients with Repeated Falls

Zwart,

Walgers,

Hemels

et al. 2023

JCM

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Background: Particularly in frail patients, anticoagulation may be underused because of the fear of bleeding. Objective: To determine whether the use of antithrombotic medication is an independent risk factor for mortality in frail elderly with repeated falls. Methods: All patients aged 65 years or older at the Fall and Syncope Clinic were eligible. Frailty was calculated with a Frailty Index (FI) based on the accumulation of deficits model. Risks were calculated with a cox regression analysis, adjusted for age, sex, and Frailty Index. Results: 663 patients were included in this analysis. The median age was 80 years, 438 were women (66%), 73% had polypharmacy, and 380 patients (57%) had cognitive impairment. The mean FI was 0.23 (sd 0.09), 182 patients were moderately frail (27.5%), and 259 (39.1%) were severely frail. A total of 140 (21%) used oral anticoagulation and 223 (34%) used antiplatelet agents. A total of 196 patients (29.6%) died during follow-up. In the adjusted cox regression model, the use of neither antiplatelets nor anticoagulation was associated with mortality. A strong association was found with frailty (HR 74.0, 95% CI 13.1–417.3) and a weak association with age (HR 1.05, 95% CI 1.03–1.08). A lower risk of mortality was seen in women (HR 0.5, 95% CI 0.3–0.6). Conclusions: In this cohort of frail older patients, there was no independent association between the use of antithrombotic medication and mortality. A strong association with mortality was found with frailty, a weak association was found with age, and a lower mortality risk was found in women. Our data indicate that the fear of bleeding or increased mortality in frail patients with an indication for oral anticoagulation may be unjustified.

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Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

The Use of Oral Anticoagulation Is Not Independently Associated with Mortality in Frail Older Patients with Repeated Falls

Zwart,

Walgers,

Hemels

et al. 2023

JCM

Self Cite

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“…Guidelines recommend screening for atrial fibrillation (AF) [ 1 , 2 ]. Patients visiting a geriatric outpatient clinic are frail and known to have a high prevalence and a high incidence of AF [ 3 , 4 ]. A recent cost-effectiveness evaluation showed the benefit of opportunistic screening for AF in the geriatric outpatient population [ 5 ].…”

Section: Introductionmentioning

confidence: 99%

Design of the Dutch multicentre study on opportunistic screening of geriatric patients for atrial fibrillation using a smartphone PPG app: the Dutch-GERAF study

Zwart,

Spruit,

Hemels

et al. 2024

Neth Heart J

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Background Screening of high-risk patients is advocated to achieve early detection and treatment of clinical atrial fibrillation (AF). The Dutch-GERAF study will address two major issues. Firstly, the effectiveness and feasibility of an opportunistic screening strategy for clinical AF will be assessed in frail older patients and, secondly, observational data will be gathered regarding the efficacy and safety of oral anticoagulation (OAC). Methods This is a multicentre study on opportunistic screening of geriatric patients for clinical AF using a smartphone photoplethysmography (PPG) application. Inclusion criteria are age ≥ 65 years and the ability to perform at least three PPG recordings within 6 months. Exclusion criteria are the presence of a cardiac implantable device, advanced dementia or a severe tremor. The PPG application records patients’ pulse at their fingertip and determines the likelihood of clinical AF. If clinical AF is suspected after a positive PPG recording, a confirmatory electrocardiogram is performed. Patients undergo a comprehensive geriatric assessment and a frailty index is calculated. Risk scores for major bleeding (MB) are applied. Standard laboratory testing and additional laboratory analyses are performed to determine the ABC-bleeding risk score. Follow-up data will be collected at 6 months, 12 months and 3 years on the incidence of AF, MB, hospitalisation, stroke, progression of cognitive disorders and mortality. Discussion The Dutch-GERAF study will focus on frail older patients, who are underrepresented in randomised clinical trials. It will provide insight into the effectiveness of screening for clinical AF and the efficacy and safety of OAC in this high-risk population. Trial registration NCT05337202.

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Frail patients who fall and their risk on major bleeding and intracranial haemorrhage. Outcomes from the Fall and Syncope Registry

et al. 2023

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Background Major bleeding, and intracranial bleeding specifically, are severe complications related to the use of anticoagulation. To what extent the risk for major bleeding is elevated among frail older people is not well known because they are underrepresented in the randomized clinical trials (RCTs). This study investigates the risk for major bleeding (MB) and intra cranial haemorrhage (ICH) in frail older people who fall. Methods All patients 65 years and older visiting the Fall and Syncope Clinic, between November 2011 and January 2020, and underwent a MRI of the brain were eligible. Frailty was assessed with a Frailty Index, based on the accumulation of deficits model. Cerebral small vessel disease was described and evaluated as proposed in the position paper of Wardlaw and colleagues in 2013. Results 479 patients were included in this analysis. Mean follow-up was 7 years per patient (ranging from 1 month to 8 years and 5 months). 368 patients (77%) were frail. A total of 81 patients used oral anticoagulation (OAC). 17 extracranial MB of which 3 were traumatic and 14 gastrointestinal, and 16 ICH occurred. There was a total of 603.4 treatment years with OAC, and 8 MBs occurred among patients on OAC (bleeding rate 1.32 per 100 treatment years), of which 2 ICHs (bleeding rate 0.33 per 100 treatment years). The risk for extracranial MB was increased by the use of antiplatelet agents (APA) (adjusted OR 6.9, CI 95% 1.2–38.3), and by the use of OAC (adjusted OR 9.8, CI 95% 1.7–56.1). The risk for ICH was only heightened by white matter hyperintensities (WMH) (adjusted OR 3.8, CI 95% 1.0-13.4). The use of APA (adjusted OR 0.9, CI 95% 0.3–3.3) or OAC (adjusted OR 0.6, CI 95% 0.1–3.3) did not elevate the risk for ICH. Conclusion In contrast to common belief, frail patients on OAC with repeated falls show a comparable bleeding rate as in the large RCTs, and the use of OAC did not increase the risk for ICH. However, the number of MBs was low, and of ICHs very low, despite extensive follow-up in this registry.

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Atrial Fibrillation, Anticoagulation, and Major Bleeding Episodes in Geriatric Patients at the Risk of Falling

Cited by 3 publications

References 25 publications

The Use of Oral Anticoagulation Is Not Independently Associated with Mortality in Frail Older Patients with Repeated Falls

The Use of Oral Anticoagulation Is Not Independently Associated with Mortality in Frail Older Patients with Repeated Falls

Design of the Dutch multicentre study on opportunistic screening of geriatric patients for atrial fibrillation using a smartphone PPG app: the Dutch-GERAF study

Frail patients who fall and their risk on major bleeding and intracranial haemorrhage. Outcomes from the Fall and Syncope Registry

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