Are the Benefits of Oral Anticoagulation Reduced in Frail AF Patients?

WASHINGTON, DC—In patients with atrial fibrillation (AF), does frailty alter the benefits of oral anticoagulation? To answer this question, researchers from Duke Clinical Research Institute, Durham, NC, investigated the Outcomes Registry for Better Informed Care in AF (ORBIT-AF) to examine the prevalence of frailty and the associated outcomes in patients with AF. This research was presented at the ACC.17 Scientific Session.

Frailty is described as having reduced physiologic reserve and increased susceptibility to disability and increases with age. Being frail “may influence the perception of bleeding risk and the decision to initiate oral anticoagulation in the elderly,” said lead author Malini Madhavan. The team evaluated all-cause mortality, stroke/TIA/non-CNS systemic embolism, composite of major adverse cardiovascular and neurologic events (CV death, myocardial infarction or stroke/transient ischemic attack [TIA]/non-CNS systemic embolism), and major bleeding.

At baseline, among 9749 patients with AF, frailty (defined by the American Geriatric Society Criteria) was identified in 6% of patients. Despite a higher median CHA₂DS₂VASc risk score (P<0.0001), frail patients were less likely to receive oral anticoagulants compared to non-frail patients (67.5% vs. 76.9%, P<0.0001). 

Frailty was also linked to increased incidence of death (adjusted HR 1.29, 95% CI: 1.08–1.55; P=0.0060), however, not with stroke/TIA/non-CNS embolism (adjusted HR 0.96, 95% CI: 0.63–1.46; P=0.8541) or major bleeding (adjusted HR 1.13, 95% CI: 0.80–1.60; P=0.4708)

Study authors reported no statistically significant interaction between frailty and oral anticoagulant use in determining outcomes of all-cause death, major bleeding, or composite endpoint of CV death, MI, stroke, TIA or non-CNS systemic embolism. 

Although frailty was associated with increased mortality, the benefits of oral anticoagulation appear to be similar in both frail and non-frail AF patients. “Hence, the presence of frailty should not be a contraindication to anticoagulation in AF patients,” concluded Madhavan.