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

Wang, Weijia; Lessard, Darleen M.; Kiefe, Catarina I.; Goldberg, Robert J.; Parish, David C.; Helm, Robert H.; Trymbulak, Katherine; Mehawej, Jordy; Abu, Hawa Ozien; Bamgbade, Benita A.; Hayward, Robert; Gore, Joel M.; Gurwitz, Jerry H.; McManus, David D.; Saczynski, Jane S.

doi:10.1111/jgs.18079

Cited by 10 publications

(12 citation statements)

References 21 publications

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“…Among patients with frailty, anticoagulation was also associated with a higher risk for death or major bleeding compared to no anticoagulation (AHR 1.26, 95% 0.69–2.30), but the difference was not significant 10 . Nonetheless, the number needed to harm with anticoagulation, defined as death, major bleeding, or stroke, was lower for frail patients than the number needed to prevent one stroke (9 vs. 34.9, respectively).…”

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confidence: 93%

“…In this issue of the Journal, Wang and colleagues report the results of a study designed to examine the association between anticoagulation and clinical outcomes in older adults with AF and comorbid cognitive impairment or frailty. 10 The authors analyzed data on 1244 patients ≥65 years of age enrolled in the Systematic Assessment of Geriatric Elements (SAGE) AF study from 2016 to 2018. Data were collected prospectively, and patients were followed until 2020 (median follow-up 2.0 years).…”

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confidence: 99%

“…Among patients with cognitive impairment ( N = 528), anticoagulation was associated with a substantially increased risk of death or major bleeding during follow‐up (adjusted hazard ratio [AHR] 2.23, 95% CI 1.08–4.61, p = 0.03) 10 . Conversely, anticoagulation was not associated with increased risk for the primary endpoint in patients without cognitive impairment (AHR 0.94, 95% CI 0.49–1.79, p = 0.80, interaction p = 0.08).…”

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confidence: 99%

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Anticoagulation for atrial fibrillation: Time to revise the paradigm?

Rich

2022

J American Geriatrics Society

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confidence: 93%

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confidence: 99%

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Anticoagulation for atrial fibrillation: Time to revise the paradigm?

Rich

2022

J American Geriatrics Society

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“…2 Oral anticoagulants are underused among all older adults with atrial fibrillation, with prevalent use estimated at 50%-60%, and even lower use for patients with frailty despite evidence of net benefit in this high-risk group. [3][4][5][6][7][8][9][10][11][12] Hospitalization is a common setting for new atrial fibrillation diagnosis. Patients may be admitted for symptomatic atrial fibrillation or it may be discovered incidentally, driven in part by frequent inpatient use of cardiac monitoring and by acute illness triggering episodes of atrial fibrillation in susceptible and paroxysmal patients.…”

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confidence: 99%

Initiation of oral anticoagulation in US older adults newly diagnosed with atrial fibrillation during hospitalization

Troy

Herzig

Trivedi

et al. 2023

J American Geriatrics Society

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BackgroundAtrial fibrillation is a common cause of stroke among older adults and is often first detected during hospitalization, given frequent use of cardiac telemetry.MethodsIn a 20% national sample of Medicare fee‐for‐service beneficiaries, we identified patients aged 65‐or‐older newly diagnosed with atrial fibrillation while hospitalized in 2016. Our primary outcome was an oral anticoagulant claim within 7‐days of discharge. Multivariable logistic regression analyses assessed relationships between anticoagulation initiation and thromboembolic and bleeding risk scores while controlling for demographics, frailty, comorbidities, and hospitalization characteristics.ResultsAmong 38,379 older adults newly diagnosed with atrial fibrillation while hospitalized (mean age 78.2 [SD 8.4]; 51.8% female; 83.3% white), 36,633 (95.4%) had an indication for anticoagulation and 24.6% (9011) of those initiated an oral anticoagulant following discharge. Higher CHA2DS2‐VASc score was associated with a small increase in oral anticoagulant initiation (predicted probability 20.5% [95% CI, 18.7%–22.3%] for scores <2 and 24.9% [CI, 24.4%–25.4%] for ≥4). Elevated HAS‐BLED score was associated with a small decrease in probability of anticoagulant initiation (25.4% [CI, 24.4%–26.4%] for score <2 and 23.1% [CI, 22.5%–23.8%] for ≥3). Frailty was associated with decreased likelihood of oral anticoagulant initiation (24.7% [CI, 23.2%–26.2%] for non‐frail and 18.1% [CI, 16.6%–19.6%] for moderately‐severely frail). Anticoagulant initiation varied by primary reason for hospitalization, with predicted probability highest among patients with a primary diagnosis of atrial fibrillation (46.1% [CI, 45.0%–47.3%]) and lowest among those with non‐cardiovascular conditions (13.8% [CI, 13.3%–14.3%]) and bleeds (3.6% [CI, 2.4%–4.8%]).ConclusionsOral anticoagulant initiation is uncommon among older adults newly diagnosed with atrial fibrillation during hospitalization, even among patients hospitalized primarily for atrial fibrillation and patients with high thromboembolic risk. Clinicians should discuss risks and benefits of oral anticoagulants with all inpatients found to have atrial fibrillation.

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We thank the authors for their interest in our work on the differential effect of anticoagulation by cognition and frailty in older patients with atrial fibrillation. 1 We appreciate their comments on the variables included in the propensity score and outcome selection. 2 We included dual antiplatelet therapy in the propensity score instead of aspirin for the following reasons.

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confidence: 99%