Frailty and atrial fibrillation: A systematic review


      • Frailty recognition in the elderly can address patient-centered care pathways.
      • Its prevalence can be four time higher among patients with atrial fibrillation(AF).
      • Its assessment may influence the way oral anticoagulation is prescribed.
      • Its presence is an important prognostic indicator among patients with AF.
      • Its recognition is mandatory to provide the best treatment among AF patients.


      Atrial fibrillation (AF) is a common cardiac arrhythmia and its prevalence increases with age. There is a significant correlation between frailty, morbidity and mortality in elderly patients with cardiovascular disease, but the relation between AF and frailty is still under debate. The aim of this study is to systematically review evidence on the association between AF and frailty.
      A systematic review of articles published between 02/01/2002 and 09/28/2017 according to PRISMA recommendations was carried out. PubMed, Web of Science, and Embase were searched for relevant articles. 11 studies were included; one longitudinal, 10 cross-sectional. Only 4 studies assessed the association of frailty with AF, while 7 studies were performed in a sample of participants with AF and did not provide any measure of association between these two conditions. The prevalence of frailty in AF patients ranged from 4.4%–75.4% while AF prevalence in the frail population ranged from 48.2%–75.4%. Selected studies enrolled an overall sample of 9420 participants. Among them, 2803 participants were diagnosed with AF and of these 1517 (54%) were frail and 1286 (46%) were pre-frail or robust. The four studies assessing the association of AF and frailty provided conflicting results.
      Evidence suggests that frailty is common in persons with AF. More research is needed to better assess the association of these conditions and to identify the optimal therapeutic approach to AF in persons with frailty.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Walston J.
        • Fried L.P.
        Frailty and the older man.
        Med Clin North Am. 1999; 83: 1173-1194
        • Ferrucci L.
        • Giallauria F.
        • Guralnik J.M.
        Epidemiology of aging.
        Radiol Clin North Am. 2008; 46 (v): 643-652
        • Fried L.P.
        • Tangen C.M.
        • Walston J.
        • et al.
        Frailty in older adults: evidence for a phenotype.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M146-56
        • Kiely D.K.
        • Cupples L.A.
        • Lipsitz L.A.
        Validation and comparison of two frailty indexes: the MOBILIZE Boston study.
        J Am Geriatr Soc. 2009; 57: 1532
        • Bandeen-Roche K.
        • Xue Q.-L.
        • Ferrucci L.
        • et al.
        Phenotype of frailty: characterization in the women's health and aging studies.
        J Gerontol A Biol Sci Med Sci. 2006; 61: 262-266
        • Cawthon P.M.
        • Marshall L.M.
        • Michael Y.
        • et al.
        Frailty in older men: prevalence, progression, and relationship with mortality.
        J Am Geriatr Soc. 2007; 55: 1216-1223
        • Clegg A.
        • Young J.
        • Iliffe S.
        • Rikkert M.O.
        • Rockwood K.
        Frailty in elderly people.
        Lancet (London, England). 2013; 381: 752-762
        • Cacciatore F.
        • Abete P.
        • Mazzella F.
        • et al.
        Frailty predicts long-term mortality in elderly subjects with chronic heart failure.
        Eur J Clin Invest. 2005; 35: 723-730
        • Khan H.
        • Kalogeropoulos A.P.
        • Georgiopoulou V.V.
        • et al.
        Frailty and risk for heart failure in older adults: the health, aging, and body composition study.
        Am Heart J. 2013; 166: 887-894
        • Newman A.B.
        • Simonsick E.M.
        • Naydeck B.L.
        • et al.
        Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability.
        JAMA. 2006; 295: 2018-2026
        • Afilalo J.
        • Alexander K.P.
        • Mack M.J.
        • et al.
        Frailty assessment in the cardiovascular care of older adults.
        J Am Coll Cardiol. 2014; 63: 747-762
        • Robinson T.N.
        • Eiseman B.
        • Wallace J.I.
        • et al.
        Redefining geriatric preoperative assessment using frailty, disability and co-morbidity.
        Ann Surg. 2009; 250: 449-455
        • Khan Z.A.
        • Aji J.
        • Soomro A.
        • Malik S.
        • Saeed W.
        • Sardar M.R.
        When we should say no to TAVR-defining the line between utility and futility.
        Cardiovasc Revasc Med. 2016; 17: 424-427
        • Ad N.
        • Holmes S.D.
        • Halpin L.
        • Shuman D.J.
        • Miller C.E.
        • Lamont D.
        The effects of frailty in patients undergoing elective cardiac surgery.
        J Card Surg. 2016; 31: 187-194
        • Naccarelli G.V.
        • Varker H.
        • Lin J.
        • Schulman K.L.
        Increasing prevalence of atrial fibrillation and flutter in the United States.
        Am J Cardiol. 2009; 104: 1534-1539
        • Go A.S.
        • Hylek E.M.
        • Phillips K.A.
        • et al.
        Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and risk factors in atrial fibrillation (ATRIA) study.
        JAMA. 2001; 285: 2370-2375
        • Heeringa J.
        • Van Der Kuip D.A.M.
        • Hofman A.
        • et al.
        Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study.
        Eur Heart J. 2006; 27: 949-953
        • Chugh S.S.
        • Blackshear J.L.
        • Shen W.K.
        • Hammill S.C.
        • Gersh B.J.
        Epidemiology and natural history of atrial fibrillation: clinical implications.
        J Am Coll Cardiol. 2001; 37: 371-378
        • Marcucci M.
        • Iorio A.
        • Nobili A.
        • et al.
        Factors affecting adherence to guidelines for antithrombotic therapy in elderly patients with atrial fibrillation admitted to internal medicine wards.
        Eur J Intern Med. 2010; 21: 516-523
        • Graham D.J.
        • Reichman M.E.
        • Wernecke M.
        • et al.
        Stroke, bleeding, and mortality risks in elderly Medicare beneficiaries treated with dabigatran or rivaroxaban for Nonvalvular atrial fibrillation.
        JAMA Intern Med. 2016; 176: 1662-1671
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • Altman D.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6e1000097
        • Nguyen T.N.
        • Cumming R.G.
        • Hilmer S.N.
        The impact of frailty on mortality, length of stay and re-hospitalisation in older patients with atrial fibrillation.
        Heart Lung Circ. 2016; 25: 551-557
        • Nguyen T.N.
        • Cumming R.G.
        • Hilmer S.N.
        Atrial fibrillation in older inpatients: are there any differences in clinical characteristics and pharmacological treatment between the frail and the non-frail?.
        Intern Med J. 2016; 46: 86-95
        • Rolfson D.B.
        • Majumdar S.R.
        • Tsuyuki R.T.
        • Tahir A.
        • Rockwood K.
        Validity and reliability of the Edmonton frail scale.
        Age Ageing. 2006; 35: 526-529
        • Annoni G.
        • Mazzola P.
        Real-world characteristics of hospitalized frail elderly patients with atrial fibrillation: can we improve the current prescription of anticoagulants?.
        J Geriatr Cardiol. 2016; 13: 226-232
        • Nadruz W.
        • Kitzman D.
        • Windham B.G.
        • et al.
        Cardiovascular dysfunction and frailty among older adults in the community: the ARIC study.
        J Gerontol Ser A Biol Sci Med Sci. 2016; 72glw199
        • Ng T.P.
        • Feng L.
        • Nyunt M.S.Z.
        • Larbi A.
        • Yap K.B.
        Frailty in older persons: multisystem risk factors and the frailty risk index (FRI).
        J Am Med Dir Assoc. 2014; 15: 635-642
        • Polidoro A.
        • Stefanelli F.
        • Ciacciarelli M.
        • et al.
        Frailty in patients affected by atrial fibrillation.
        Arch Gerontol Geriatr. 2013; 57: 325-327
        • Perera V.
        • Bajorek B.V.
        • Matthews S.
        • Hilmer S.N.
        The impact of frailty on the utilisation of antithrombotic therapy in older patients with atrial fibrillation.
        Age Ageing. 2009; 38: 156-162
        • Newman A.B.
        • Gottdiener J.S.
        • Mcburnie M.A.
        • et al.
        Associations of subclinical cardiovascular disease with frailty.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M158-66
        • Gharacholou S.M.
        • Tashiro T.
        • Cha S.S.
        • et al.
        Echocardiographic indices associated with frailty in adults ≥65 years.
        Am J Cardiol. 2015; 116: 1591-1595
        • Frisoli A.
        • Ingham S.J.M.
        • Paes Â.T.
        • et al.
        Frailty predictors and outcomes among older patients with cardiovascular disease: data from Fragicor.
        Arch Gerontol Geriatr. 2015; 61: 1-7
        • Mlynarska A.
        • Mlynarski R.
        • Golba K.S.
        Older age and a higher EHRA score allow higher levels of frailty syndrome to be predicted in patients with atrial fibrillation.
        Aging Male. 2017; 20: 23-27
        • Palmer K.
        • Marengoni A.
        • Russo P.
        • et al.
        Frailty and drug use.
        J Frailty Aging. 2016; 5: 100-103
        • Marengoni A.
        • Nobili A.
        • Onder G.
        Best practices for drug prescribing in older adults: acall for action.
        Drugs Aging. 2015; 32: 887-890
        • Marengoni A.
        • Onder G.
        Guidelines, polypharmacy, and drug-drug interactions in patients with multimorbidity.
        BMJ. 2015; 350h1059
        • Bo M.
        • Li Puma F.
        • Badinella Martini M.
        • et al.
        Effects of oral anticoagulant therapy in older medical in-patients with atrial fibrillation: a prospective cohort observational study.
        Aging Clin Exp Res. 2017; 29: 491-497
        • Induruwa I.
        • Evans N.R.
        • Aziz A.
        • et al.
        Clinical frailty is independently associated with non-prescription of anticoagulants in older patients with atrial fibrillation.
        Geriatr Gerontol Int. 2017; : 1-6
        • Kim S.
        • Yoon S.
        • Choi J.
        • et al.
        Clinical implication of frailty assessment in older patients with atrial fibrillation.
        Arch Gerontol Geriatr. 2017; 70: 1-7
        • Nguyen T.N.
        • Morel-Kopp M.C.
        • Pepperell D.
        • Cumming R.G.
        • Hilmer S.N.
        • Ward C.M.
        The impact of frailty on coagulation and responses to warfarin in acute older hospitalised patients with atrial fibrillation: a pilot study.
        Aging Clin Exp Res. 2017; 0: 1-10