Joint use of cardio-embolic and bleeding risk scores in elderly patients with atrial fibrillation

Abstract

Background: Scores for cardio-embolic and bleeding risk in patients with atrial fibrillation are described in the literature. However, it is not clear how they co-classify elderly patients with multimorbidity, nor whether and how they affect the physician's decision on thromboprophylaxis. Methods: Four scores for cardio-embolic and bleeding risks were retrospectively calculated for ≥65 year old patients with atrial fibrillation enrolled in the REPOSI registry. The co-classification of patients according to risk categories based on different score combinations was described and the relationship between risk categories tested. The association between the antithrombotic therapy received and the scores was investigated by logistic regressions and CART analyses. Results: At admission, among 543 patients the median scores (range) were: CHADS 2 2 (0-6), CHA 2 DS 2 -VASc 4 (1-9), HEMORR 2 HAGES 3 (0-7), HAS-BLED 2 (1-6). Most of the patients were at high cardio-embolic/high-intermediate bleeding risk (70.5% combining CHADS 2 and HEMORR 2 HAGES, 98.3% combining CHA 2 DS 2 -VASc and HAS-BLED). 50-60% of patients were classified in a cardio-embolic risk category higher than the bleeding risk category. In univariate and multivariable analyses, a higher bleeding score was negatively associated with warfarin prescription, and positively associated with aspirin prescription. The cardio-embolic scores were associated with the therapeutic choice only after adjusting for bleeding score or age. Conclusion: REPOSI patients represented a population at high cardio-embolic and bleeding risks, but most of them were classified by the scores as having a higher cardio-embolic than bleeding risk. Yet, prescription and type of antithrombotic therapy appeared to be primarily dictated by the bleeding risk.

Barriers to prescribing oral anticoagulants to inpatients aged 80 years and older with nonvalvular atrial fibrillation: a cross-sectional study

“…We found that the prevalence of underprescription of OACs was particularly high among patients who were taking antiplatelets. These results were in line with previous studies [ 5 , 6 , 18 , 20 – 23 ]. Our results showed that 44.0% of NVAF patients aged ≥ 80 years were prescribing antiplatelets, and 25.9% of patients received antiplatelet monotherapy.…”

Oral anticoagulant use in octogenarian European patients with atrial fibrillation: A subanalysis of PREFER in AF

“…Factors for long considered barriers to anticoagulant use in the elderly, such as frequent comorbidities, fear of bleeding and unawareness of guidelines [3] might have been overcome because of the increase of evidence for the benefit of anticoagulant therapy especially in the AF elderly population [29]. On the other hand, the specific setting, i.e., patients, mostly outpatients, referred to cardiologists, might also explain the very high frequency of OAC use compared with what shown in other settings, e.g., inpatients admitted to internal medicine or geriatric wards [30].…”

Characterization of patients with atrial fibrillation not treated with oral anticoagulants

“…elevated bleeding risk). However, patients with a high risk of bleeding may also have a high risk of stroke [ 17 , 18 ]. This complicates the assessment of the risk–benefit ratio in patients with AF.…”