Key result
Oral anticoagulants linked to ~18% lower 1-year mortality risk in frail AF patients.
Why the study?
Morbidity and mortality linked to high CHA2DS2-VASc and HAS-BLED scores are not specific to AF, and frailty may be an important contributor. The authors evaluated the association of stroke and bleeding risk scores with noncardiovascular frail events and assessed stroke prevention therapy outcomes in frail AF patients.
Does oral anticoagulant use reduce mortality, stroke, or bleeding in frail patients with atrial fibrillation?
Cohort (n=213,435)
Yes
Does oral anticoagulant use reduce mortality, stroke, or bleeding in frail patients with atrial fibrillation?
In frail patients with atrial fibrillation, oral anticoagulant use is associated with reduced 1-year mortality without significantly increasing major bleeding.
Supports OAC consideration in frail AF; leaves open RCT confirmation of mortality benefit.
Morbidity and mortality associated with high CHA2DS2-VASc and HAS-BLED scores is not specific to atrial fibrillation (AF). Frailty could be an important contributor to this morbidity and mortality while being mechanistically independent from AF. We sought to evaluate the association of stroke and bleeding risk to noncardiovascular frail events and the association of stroke prevention therapy to outcomes in frail patients with AF. Using the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF) study from the Veterans Health Administration, we identified patients with newly diagnosed AF from 2004 to 2014. Baseline frailty was identified using a previously validated claims-based index requiring ≥2 of 12 ICD-9 diagnoses. Logistic regressions modeled the association between CHA2DS2-VASc and modified HAS-BLED and frailty. Cox proportional hazard regressions were used to evaluate the association between CHA2DS2-VASc and modified HAS-BLED and a composite of noncardiovascular frail events (fractures, urinary tract infections, bacterial pneumonia, or dehydration). We also evaluated the association of oral anticoagulant (OAC) use with stroke, bleeding, and 1-year mortality in frail patients and non-frail patients. In 213,435 patients (age 70 ± 11; 98% male; CHA2DS2-VASc 2.4 ± 1.7) with AF, 8,498 (4%) were frail. CHA2DS2-VASc > 0 and HAS-BLED > 0 were strongly associated with frailty (odds ratio [OR] 13.3 (95% CI: 11.6-15.2) for CHA2DS2-VASc 4+ and OR 13.4 (10.2-17.5) for HAS-BLED 3+). After adjusting for covariates, CHA2DS2-VASc, and HAS-BLED > 0 were associated with higher risk of non-cardiovascular frail events (hazard ratio [HR] 2.1 (95% CI: 2.0-2.2) for CHA2DS2-VASc 4+ and HR 1.4 (95% CI: 1.3-1.5) for HAS-BLED 3+). In frail patients, OAC use was associated with significantly lower risk of 1-year mortality (HR 0.82; 95% CI 0.72-0.94, P = .0031) but did not reach significance for risk of stroke (HR 0.80; 95% CI 0.55-1.18, P = .26) or major bleeding (HR 1.08; 95% CI 0.93-1.25, P = .34). High CHA2DS2-VASc and HAS-BLED scores are strongly associated with frailty. However, in frail patients, OAC use was associated with reduction in 1-year mortality. For this challenging clinical population with competing risks of frailty and frail events, focused prospective studies are needed to support clinical decision-making. Until then, careful evaluation of frailty should inform shared decision-making.
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Pundi et al. (2023) conducted a cohort in Atrial fibrillation (n=213,435). Oral anticoagulants (OAC) vs. No OAC was evaluated on 1-year mortality in frail patients (HR 0.82, 95% CI 0.72-0.94, p=0.0031). In frail patients with atrial fibrillation, oral anticoagulant use was associated with a significantly lower risk of 1-year mortality (HR 0.82; 95% CI 0.72-0.94, P=0.0031).
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