Risk scores and geriatric profile: can they really help us in anticoagulation decision making among older patients suffering from atrial fibrillation?

Abstract

ObjectivesAnticoagulation for the prevention of cardio-embolism is most frequently indicated but largely underused in frail older patients with atrial fibrillation (AF). This study aimed at identifying characteristics associated with anticoagulation underuse.MethodsA cross-sectional study of consecutive geriatric patients aged ≥75 years, with AF and clear anticoagulation indication (CHADS2 [Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack] ≥2) upon hospital admission. All patients benefited from a comprehensive geriatric assessment. Their risks of stroke and bleeding were predicted using CHADS2 and HEMORR2HAGES (Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age >75 years), Reduced platelet count or function, Rebleed risk, Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, and Stroke) scores, respectively.ResultsAnticoagulation underuse was observed in 384 (50%) of 773 geriatric patients with AF (median age 85 years; female 57%, cognitive disorder 33%, nursing home 20%). No geriatric characteristic was found to be associated with anticoagulation underuse. Conversely, anticoagulation underuse was markedly increased in the patients treated with aspirin (odds ratio [OR] [95% confidence interval]: 5.3 [3.8; 7.5]). Other independent predictors of anticoagulation underuse were ethanol abuse (OR: 4.0 [1.4; 13.3]) and age ≥90 years (OR: 2.0 [1.2; 3.4]). Anticoagulation underuse was not inferior in patients with a lower bleeding risk and/or a higher stroke risk and underuse was surprisingly not inferior either in the AF patients who had previously had a stroke.ConclusionHalf of this geriatric population did not receive any anticoagulation despite a clear indication, regardless of their individual bleeding or stroke risks. Aspirin use is the main characteristic associated with anticoagulation underuse.

Impact of Age, Multimorbidity and Frailty on the Prescription of Preventive Antiplatelet Therapy in Older Population

“…The CGA did not individualize any factor associated with PAI prescription. To our knowledge, such findings have never been published for PAI, but similar results were found for anticoagulants in a geriatric setting [40]. We found no link between motor disability or falls and the prescription of PAI.…”

Atrial Fibrillation in Older People: Concepts and Controversies

“…Studies looking into OAC prescription rates in frail people have been variable. While practices in countries such as Australia and Mexico have shown that frailty status predicted OAC use in older adults (109, 116) there is also evidence to suggest a lack of association between the two (117, 118). This is likely a reflection of the variations in practice and guideline recommendations between the regions as well as the perception of frailty by those assessing it.…”

Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach

“…It has been reported that decreased kidney function and lower hemoglobin levels are associated with an increased risk for new-onset AF, especially when both are present [ 35 ]. On the other hand, thrombocytopenia is associated with an increased risk of hemorrhage [ 36 , 37 ]. In HAS-BLED, bleeding refers to previous bleeding history and/or predisposition to bleed (i.e.…”