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Long-term effectiveness and safety of anticoagulation therapy in oldest old, frail people with atrial fibrillation

Published:February 04, 2021DOI:https://doi.org/10.1016/j.ejim.2021.01.020

      Highlights

      • Atrial fibrillation represents a major cause of mortality in older people.
      • Frail and oldest-old patients are rarely included in clinical trials.
      • Frail anticoagulated patients survived longer that not-anticoagulated ones.
      • The risk of clinically relevant bleeding was not significantly increased.
      • Comprehensive geriatric assessment may be useful in anticoagulation decision making.

      Abstract

      Background

      Atrial Fibrillation (AF) represents a major cause of mortality and morbidity in older people; however, oldest-old frail patients are usually excluded from clinical trials. Aim of the study is to evaluate the impact of oral anticoagulation (OAC) therapy on long-term overall survival and clinically relevant bleedings in a large cohort of hospitalised frail, oldest-old patients with AF.

      Patients and methods

      Prospective, observational, cohort study, evaluating patients consecutively hospitalized for acute illnesses in our Geriatrics Unit (January 2013-July 2017). Participants were divided in two groups, AF and sinus rhythm (SR). Besides recording demographic characteristics and clinical history, comprehensive geriatric assessment (CGA) was obtained.

      Results

      AF patients [1808/5093 (35.5%), 58.5% women] were older, with higher burden of comorbidity than those with SR. At discharge, HAS-BLED [OR 0.77 (95%CI 0.67-0.90), cognitive impairment [OR 0.92 (95%CI 0.90-0.95)], malnutrition [OR 0.74 (95%CI 0.57-0.97)] and CHA2DS2VASc [OR 1.33 (95%CI 1.20-1.47)] emerged as significant independent predictors of anticoagulant prescription. AF patients showed significantly reduced overall survival (OS) than those with SR (11.4 vs 19.4 months, p<.001). However, anticoagulated AF patients (75.2%) had three-times longer OS than those not anticoagulated (15.0 vs 5.6 months, p<.001), comparable to SR patients after adjustment for potential confounders [HR 1.04 (95%CI 0.99–1.10)]. ED readmittance risk for clinically relevant bleeding did not differ between AF patients receiving or not anticoagulation [HR 1.04 (95%CI 0.76-1.14)]

      Conclusion

      anticoagulation therapy was associated with significant increase of long-term OS without increased risk of clinically relevant bleeding. CGA resulted an useful tool in OAC therapy decision-making.

      Keywords

      Abbreviations:

      AF (atrial fibrillation), VKA (vitamin-K, antagonist), DOACs (direct-acting oral anticoagulants), ED (emergency department), CGA (comprehensive geriatric assessment), CIRS (Cumulative Illness Rating Scale), ADL (activities of daily living), IADL (instrumental activities of daily living), SPMSQ (Short Portable Mental Status Questionnaire), MNA (mini-nutritional assessment)
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