Clinical Research
The Effect of Bleeding Risk and Frailty Status on Anticoagulation Patterns in Octogenarians With Atrial Fibrillation: The FRAIL-AF Study

https://doi.org/10.1016/j.cjca.2015.05.012Get rights and content

Abstract

Background

Older adults are at increased risk of atrial fibrillation (AF), its thromboembolic complications, and bleeding. A significant percentage of octogenarians do not receive anticoagulation therapy. The objective of this study was to investigate the effect of thromboembolic risk, bleeding risk, and frailty on the anticoagulation status of octogenarians hospitalized with AF.

Methods

A cross-sectional study was conducted in 682 hospitalized patients aged 80 years and older with AF or atrial flutter in Montreal, Québec. Consumption of warfarin or a new oral anticoagulant was documented. Medical record data were used to determine each patient's frailty status using the Clinical Frailty Scale (CFS) and to evaluate the risk of stroke (CHADS2 [Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack]) and bleeding (HAS-BLED [Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years) Drugs/alcohol concomitantly]). Univariable and multivariable logistic regression analyses were used to examine the effect of frailty status and the risk of stroke and bleeding on the probability of receiving anticoagulation therapy.

Results

Seventy percent of octogenarians with AF received anticoagulation therapy (n = 475). A high risk of stroke (CHADS2 = 3 compared with CHADS2 = 1, odds ratio [OR], 3.58; 95% confidence interval [CI], 1.09-11.77), and the absence of severe frailty (CFS < 7; OR, 3.41; 95% CI, 1.84-6.33) were independently associated with anticoagulant use in multivariable analyses. A high risk of bleeding (HAS-BLED score ≥ 3; OR, 0.33; 95% CI, 0.12-0.86) was associated with the absence of anticoagulation.

Conclusions

Our study suggests a higher prevalence of appropriate anticoagulation among octogenarians with AF than reported in previous studies. Further work is needed to develop and disseminate tools to optimize the use of anticoagulants in this high-risk population.

Résumé

Introduction

Les personnes âgées sont exposées à une augmentation du risque de fibrillation auriculaire (FA), à ses complications thromboemboliques et de saignement. Un pourcentage important d’octogénaires ne reçoivent pas de traitement anticoagulant. L’objectif de cette étude était d’examiner les conséquences du risque thrombo-embolique, du risque de saignement et la fragilité à l’anticoagulation des octogénaires hospitalisés souffrant d’une FA.

Méthodes

Une étude transversale a été menée auprès de 682 patients hospitalisés âgés de 80 ans et plus qui souffraient de FA ou de flutter auriculaire à Montréal, au Québec. La prise de warfarine ou d’un nouvel anticoagulant oral a été documentée. Les données des dossiers médicaux ont été utilisées pour déterminer la fragilité de chacun des patients à l'aide de la Clinical Frailty Scale (CFS) et pour évaluer le risque d'accident vasculaire cérébral (CHADS2 [Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack, soit l’insuffisance cardiaque congestive, l’hypertension, l’âge, le diabète, l’accident vasculaire cérébral/l’ischémie cérébrale transitoire]) et de saignement (HAS-BLED [Hypertension, Abnormal Renal/Liver function, Stroke, Bleeding History or predisposition, Labile International Normalized Ratio, Elderly (> 65 years) Drugs/Alcohol Concomitantly], soit l'hypertension, les anomalies de la fonction rénale ou hépatique, l'accident vasculaire cérébral, les antécédents de saignement ou la prédisposition à saigner, la labilité du rapport international normalisé, les personnes âgées [> 65 ans], l'usage concomitant de médicaments ou d'alcool). Les analyses univariées et multivariées de régression logistique ont été utilisées pour examiner les conséquences de la fragilité et le risque d’accident vasculaire cérébral et de saignement sur la probabilité de recevoir le traitement anticoagulant.

Résultats

Soixante-dix pour cent des octogénaires souffrant de FA ont reçu le traitement anticoagulant (n = 475). Un risque élevé d’accident vasculaire cérébral (CHADS2 = 3 comparativement au CHADS2 = 1, ratio d’incidence approché [RIA], 3,58; intervalle de confiance [IC] à 95 %, 1,09-11,77) et l’absence de fragilité importante (CFS < 7; RIA, 3,41; IC à 95 %, 1,84-6,33) ont été indépendamment associés à l’utilisation d’un anticoagulant dans les analyses multivariées. Un risque élevé de saignement (score HAS-BLED ≥ 3; RIA, 0,33; IC à 95 %, 0,12-0,86) a été associé à l’absence d’anticoagulation.

Conclusions

Notre étude suggère une plus forte prévalence à l’anticoagulation appropriée chez les octogénaires souffrant de FA que ce qui a été rapporté par les études précédentes. Des études supplémentaires sont nécessaires pour élaborer et diffuser des outils pour optimiser l’utilisation des anticoagulants dans cette population exposée à un risque élevé.

Section snippets

Study design and population

A cross-sectional study was conducted in 682 patients aged 80 years and older with AF or AFL admitted to 3 academic hospitals in Montreal, Québec from January 1, 2012-December 31, 2013. Patients were identified for inclusion in the study by the medical archivist using the International Classification of Diseases 10th Revision (ICD-10) diagnostic codes I48 for AF and AFL. Patients were excluded if they met any of the following criteria: age < 80 years, death during hospitalization,

Patient characteristics

A total of 1024 patients were randomly screened from a list of 1314 patients with AF or AFL who were hospitalized from January 1, 2012-December 30, 2013. Six hundred eighty-two patients met the inclusion criteria for the study (Fig. 1). Of these patients, 475 (69.6%) received anticoagulation therapy—373 (78.5%) were prescribed warfarin, 98 (20.6%) were prescribed a new oral anticoagulant agent (ie, dabigatran, rivaroxaban, or apixaban), 3 (0.6%) received a therapeutic dose of a

Discussion

A number of factors appear to influence the decision to prescribe anticoagulation therapy for octogenarians with AF or AFL. A high risk of thromboembolism was significantly associated with the decision to prescribe anticoagulation therapy in this study, regardless of age and bleeding risk, whereas a higher risk of bleeding led to abstention from prescribing anticoagulation therapy. Patients classified as nonfrail to only moderately frail were 3.5 times more likely to receive anticoagulation

Conclusions

Contemporary practice in 3 Canadian academic hospitals suggests that the decision to prescribe anticoagulation therapy to octogenarians with AF or AFL is influenced by a complex interplay of thromboembolic risk, bleeding risk, and frailty status. Rates of anticoagulation are clearly diminished among patients who are severely frail with advanced disability. Whether or not a 70% anticoagulation rate is reasonable remains to be determined by longitudinal studies that evaluate the thromboembolic

Acknowledgements

The authors thank Dr Fadi Massoud, Dr Judith Latour, Dr Isabelle Payot, Dr Thien Tuong Minh Vu, and Dr Marie-Jeanne Kergoat for their contribution to the development of the methodology of the Frailty, Stroke Risk and Bleeding Risk on Anticoagulation in the Elderly With Atrial Fibrillation (FRAIL-AF) study. We also express gratitude to biostatistician Martin Ladouceur for his statistical assistance.

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