Clinical question: In older patients with atrial fibrillation (AFib), does frailty or cognitive function affect the risk of anticoagulation use?
Dr. Enix
Background: In older patients with AFib, both the risk of stroke and the use of preventative anticoagulation are common. However, the impact of cognitive impairment and frailty on the risks of anticoagulation use in older patients with AFib is unknown.
Study design: Observational prospective cohort study
Setting: Seven ambulatory cardiology and internal medicine centers in Massachusetts and Georgia, between 2016 and 2018
Synopsis: 1,244 patients 65 years and older (average 75.5) with AFib were enrolled, and outcomes were observed during two years. Participants had CHADS2-VASC scores >2 (average 4.4). Cognitive function and frailty were determined using the Montreal Cognitive Assessment Battery and Fried frailty scale, respectively; 528 cognitively impaired individuals (42.4%) and 172 frail participants (13.8%) were observed. There were higher rates of composite major bleeding and death in individuals with cognitive impairment (adjusted HR, 2.23; 95% CI, 1.08 to 4.61) compared to those without (adjusted HR, 0.94; 95% CI, 0.49 to 1.79; P for interaction = 0.08). The number needed to harm was 8.4 for major bleeding and death among cognitively impaired individuals compared to 103 in cognitively intact. There was no significant difference in major bleeding or death among participants with or without frailty. Limitations include the study’s observational nature and inability to attribute causation. The low prevalence of frail patients limits the ability to evaluate clinical outcomes based on frailty status. Additionally, the incidence of stroke in this study was lower than in prior historic trials, underpowering stroke as an outcome.
Bottom line: Anticoagulation for AFib was associated with a higher incidence of major bleeding events and death in patients 65 years of age and older with cognitive impairment. There was no significant difference in harms associated with anticoagulation use based on frailty status.
Citation: Wang W, Lessard D, et al. Differential effect of anticoagulation according to cognitive function and frailty in older patients with atrial fibrillation. J Am Geriatr Soc. 2023;71(2):394-403.
Dr. Enix is an assistant professor in the division of hospital medicine at the University of Colorado Anshutz Medical Campus in Aurora, Colo.