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

Abstract

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.

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

“…Although current guidelines suggest avoiding OAT prescription on very frail older patients with AF, 2 based on Dr. Wang and colleagues' findings, the presence of frailty syndrome does not appear to be associated with an increased risk of major bleeding or death at the 2-year follow-up. This seems to contradict a recent study published in JAGS by Candeloro et al, 3 showing an increased bleeding risk with advancing frailty degree in older outpatients with AF.…”

Frailty, Home Time, and Health Care Costs in Older Adults With Atrial Fibrillation Receiving Oral Anticoagulants

“… 1 , 2 , 3 Despite the availability of direct oral anticoagulants (DOACs), 4 , 5 , 6 , 7 the use of oral anticoagulants (OACs) remains suboptimal in older adults with AF. 3 Frailty is among the main concerns that complicate prescribing decisions 8 and is highly associated with the risk of bleeding, 9 falls, 10 and drug-related adverse events. 11 Although the prevalence of frailty in older adults with AF ranges from 17% in the community to 62% in the hospital, 12 patients with frailty are severely underrepresented in clinical trials, leading to limited data to inform OAC prescribing 8 and suboptimal use in older adults with AF and with frailty.…”