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Influence of frailty on anticoagulant prescription and clinical outcomes after 1-year follow-up in hospitalised older patients with atrial fibrillation

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A Correction to this article was published on 25 January 2019

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Abstract

Frailty is an important prognostic factor in older adults with cardiovascular diseases. We aim to describe the characteristics of elderly hospitalised frail patients with non-valvular atrial fibrillation (NVAF) and to assess the influence of frailty, along with other functional and health status variables on anticoagulation prescription, 1-year all-cause mortality, and the incidence of ischemic and bleeding complications. An observational, prospective multicentre study was carried out on patients with NVAF over the age of 75, who were admitted to the Internal Medicine departments in Spain. A total of 615 patients were evaluated (mean age 85.23 ± 5.16 years, 54.3% females, 48.3% frail). Frail patients had higher CHA2DS2-VASc and HAS-BLED scores, more comorbidities and worse functional status and cognitive impairment compared to non-frail. During hospitalisation, 58 (9.4%) patients died (12.5% frail, 6.6% non-frail, p = 0.01). Among the participants discharged, 69.8% received anticoagulants, 13% anti-platelets only and 16.9% no anti-thrombotics, with no difference by frailty status. Frailty is not a predictor of anticoagulant prescription at discharge (OR 0.93, 95% CI 0.55–1.57), while functional dependency remains significantly associated (OR for severe dependency 0.44, 95% CI 0.23–0.82). After the 1-year follow-up, frail patients have a higher risk of death (HR 1.99, 95% CI 1.43–2.76). Among patients taking anticoagulants, the incidence of stroke and major bleeding is similar between frailty groups. In our study, frailty is related to worse global health status. It has no impact on antithrombotic prescription, nor is a predictor of AF complications, even though frail subjects have a higher mortality during hospitalisation and after 1-year follow-up.

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  • 25 January 2019

    In the original publication, all the collaborator names were incorrectly tagged and published online. The correct given and family names for the collaborators names should list as follows.

References

  1. Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, Cesari M, Chumlea WC, Doehner W, Evans J, Fried LP, Guralnik JM, Katz PR, Malmstrom TK, McCarter RJ, Gutierrez Robledo LM, Rockwood K, von Haehling S, Vandewoude MF, Walston J (2013) Frailty consensus: a call to action. J Am Med Dir Assoc 14(6):392–397. https://doi.org/10.1016/j.jamda.2013.03.022

    Article  PubMed  PubMed Central  Google Scholar 

  2. Martinez-Reig M, Flores Ruano T, Fernandez Sanchez M, Nogueron Garcia A, Romero Rizos L, Abizanda Soler P (2016) Frailty and long term mortality, disability and hospitalisation in Spanish older adults. The FRADEA Study. Rev Esp Geriatr Gerontol 51(5):254–259. https://doi.org/10.1016/j.regg.2016.01.006

    Article  PubMed  Google Scholar 

  3. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA (2001) Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 56(3):M146–M156

    Article  PubMed  CAS  Google Scholar 

  4. von Haehling S, Anker SD, Doehner W, Morley JE, Vellas B (2013) Frailty and heart disease. Int J Cardiol 168(3):1745–1747. https://doi.org/10.1016/j.ijcard.2013.07.068

    Article  Google Scholar 

  5. Cacciatore F, Abete P, Mazzella F, Viati L, Della Morte D, D’Ambrosio D, Gargiulo G, Testa G, Santis D, Galizia G, Ferrara N, Rengo F (2005) Frailty predicts long-term mortality in elderly subjects with chronic heart failure. Eur J Clin Invest 35(12):723–730. https://doi.org/10.1111/j.1365-2362.2005.01572.x

    Article  PubMed  CAS  Google Scholar 

  6. Ekerstad N, Swahn E, Janzon M, Alfredsson J, Lofmark R, Lindenberger M, Andersson D, Carlsson P (2014) Frailty is independently associated with 1-year mortality for elderly patients with non-ST-segment elevation myocardial infarction. Eur J Prev Cardiol 21(10):1216–1224. https://doi.org/10.1177/2047487313490257

    Article  PubMed  Google Scholar 

  7. Polidoro A, Stefanelli F, Ciacciarelli M, Pacelli A, Di Sanzo D, Alessandri C (2013) Frailty in patients affected by atrial fibrillation. Arch Gerontol Geriatr 57(3):325–327. https://doi.org/10.1016/j.archger.2013.04.014

    Article  PubMed  CAS  Google Scholar 

  8. Lopez Soto A, Formiga F, Bosch X, Garcia Alegria J (2012) Prevalence of atrial fibrillation and related factors in hospitalized old patients: ESFINGE study. Med Clin (Barc) 138(6):231–237. https://doi.org/10.1016/j.medcli.2011.05.023

    Article  Google Scholar 

  9. Wolf PA, Abbott RD, Kannel WB (1991) Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke 22(8):983–988

    Article  PubMed  CAS  Google Scholar 

  10. Singer DE, Chang Y, Fang MC, Borowsky LH, Pomernacki NK, Udaltsova N, Go AS (2009) The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Ann Intern Med 151(5):297–305

    Article  PubMed  PubMed Central  Google Scholar 

  11. Mazzone A, Bo M, Lucenti A, Galimberti S, Bellelli G, Annoni G (2016) The role of comprehensive geriatric assessment and functional status in evaluating the patterns of antithrombotic use among older people with atrial fibrillation. Arch Gerontol Geriatr 65:248–254. https://doi.org/10.1016/j.archger.2016.04.008

    Article  PubMed  CAS  Google Scholar 

  12. Bo M, Sciarrillo I, Maggiani G, Falcone Y, Iacovino M, Grisoglio E, Fonte G, Grosjean S, Gaita F (2017) Health status, geriatric syndromes and prescription of oral anticoagulant therapy in elderly medical inpatients with atrial fibrillation. Geriatr Gerontol Int 17(3):416–423. https://doi.org/10.1111/ggi.12730

    Article  PubMed  Google Scholar 

  13. Perera V, Bajorek BV, Matthews S, Hilmer SN (2009) The impact of frailty on the utilisation of antithrombotic therapy in older patients with atrial fibrillation. Age Ageing 38(2):156–162. https://doi.org/10.1093/ageing/afn293

    Article  PubMed  Google Scholar 

  14. Lefebvre MC, St-Onge M, Glazer-Cavanagh M, Bell L, Kha Nguyen JN, Viet-Quoc Nguyen P, Tannenbaum C (2016) The effect of bleeding risk and frailty status on anticoagulation patterns in octogenarians with atrial fibrillation: the FRAIL-AF study. Can J Cardiol 32(2):169–176. https://doi.org/10.1016/j.cjca.2015.05.012

    Article  PubMed  Google Scholar 

  15. Gullon A, Suarez C, Diez-Manglano J, Formiga F, Cepeda JM, Pose A, Camafort M, Castiella J, Rovira E, Mostaza JM (2017) Antithrombotic treatment and characteristics of elderly patients with non-valvular atrial fibrillation hospitalized at internal medicine departments. NONAVASC registry. Med Clin (Barc) 148(5):204–210. https://doi.org/10.1016/j.medcli.2016.10.042

    Article  Google Scholar 

  16. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P (2016) 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 37(38):2893–2962. https://doi.org/10.1093/eurheartj/ehw210

    Article  PubMed  Google Scholar 

  17. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ (2010) Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest 137(2):263–272. https://doi.org/10.1378/chest.09-1584

    Article  PubMed  Google Scholar 

  18. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY (2010) A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 138(5):1093–1100. https://doi.org/10.1378/chest.10-0134

    Article  PubMed  Google Scholar 

  19. Morley JE, Malmstrom TK, Miller DK (2012) A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging 16(7):601–608

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  20. Woo J, Leung J, Morley JE (2012) Comparison of frailty indicators based on clinical phenotype and the multiple deficit approach in predicting mortality and physical limitation. J Am Geriatr Soc 60(8):1478–1486. https://doi.org/10.1111/j.1532-5415.2012.04074.x

    Article  PubMed  Google Scholar 

  21. Lopez D, Flicker L, Dobson A (2012) Validation of the frail scale in a cohort of older Australian women. J Am Geriatr Soc 60(1):171–173. https://doi.org/10.1111/j.1532-5415.2011.03746.x

    Article  PubMed  Google Scholar 

  22. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383

    Article  PubMed  CAS  Google Scholar 

  23. Mahoney FI, Barthel DW (1965) Functional evaluation: the Barthel index. Md State Med J 14:61–65

    PubMed  CAS  Google Scholar 

  24. Pfeiffer E (1975) A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 23(10):433–441

    Article  PubMed  CAS  Google Scholar 

  25. Malmstrom TK, Morley JE (2013) SARC-F: a simple questionnaire to rapidly diagnose sarcopenia. J Am Med Dir Assoc 14(8):531–532. https://doi.org/10.1016/j.jamda.2013.05.018

    Article  PubMed  Google Scholar 

  26. Schulman S, Kearon C (2005) Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost: JTH 3(4):692–694. https://doi.org/10.1111/j.1538-7836.2005.01204.x

    Article  PubMed  CAS  Google Scholar 

  27. Nguyen TN, Cumming RG, Hilmer SN (2016) Atrial fibrillation in older inpatients: are there any differences in clinical characteristics and pharmacological treatment between the frail and the non-frail? Intern Med J 46(1):86–95. https://doi.org/10.1111/imj.12912

    Article  PubMed  CAS  Google Scholar 

  28. Scowcroft AC, Lee S, Mant J (2013) Thromboprophylaxis of elderly patients with AF in the UK: an analysis using the General Practice Research Database (GPRD) 2000–2009. Heart 99(2):127–132. https://doi.org/10.1136/heartjnl-2012-302843

    Article  PubMed  Google Scholar 

  29. Hylek EM, D’Antonio J, Evans-Molina C, Shea C, Henault LE, Regan S (2006) Translating the results of randomized trials into clinical practice: the challenge of warfarin candidacy among hospitalized elderly patients with atrial fibrillation. Stroke 37(4):1075–1080. https://doi.org/10.1161/01.STR.0000209239.71702.ce

    Article  PubMed  Google Scholar 

  30. Kim SW, Yoon SJ, Choi JY, Kang MG, Cho Y, Oh IY, Kim CH, Kim KI (2017) Clinical implication of frailty assessment in older patients with atrial fibrillation. Arch Gerontol Geriatr 70:1–7. https://doi.org/10.1016/j.archger.2016.12.001

    Article  PubMed  Google Scholar 

  31. Sanchez-Barba B, Navarrete-Reyes AP, Avila-Funes JA (2013) Are geriatric syndromes associated with reluctance to initiate oral anticoagulation therapy in elderly adults with nonvalvular atrial fibrillation? J Am Geriatr Soc 61(12):2236–2237. https://doi.org/10.1111/jgs.12582

    Article  PubMed  Google Scholar 

  32. Diez-Manglano J, Bernabeu-Wittel M, Murcia-Zaragoza J, Escolano-Fernandez B, Jarava-Rol G, Hernandez-Quiles C, Oliver M, Sanz-Baena S (2017) Oral anticoagulation in patients with atrial fibrillation and medical non-neoplastic disease in a terminal stage. Intern Emerg Med 12(1):53–61. https://doi.org/10.1007/s11739-016-1517-4

    Article  PubMed  Google Scholar 

  33. Blodgett J, Theou O, Kirkland S, Andreou P, Rockwood K (2015) Frailty in NHANES: comparing the frailty index and phenotype. Arch Gerontol Geriatr 60(3):464–470. https://doi.org/10.1016/j.archger.2015.01.016

    Article  PubMed  Google Scholar 

  34. Hsu JC, Chan PS, Tang F, Maddox TM, Marcus GM (2015) Differences in anticoagulant therapy prescription in patients with paroxysmal versus persistent atrial fibrillation. Am J Med 128(6):654.e651. https://doi.org/10.1016/j.amjmed.2014.11.035

    Article  Google Scholar 

  35. Suarez Fernandez C, Formiga F, Camafort M, Cepeda Rodrigo M, Diez-Manglano J, Pose Reino A, Tiberio G, Mostaza JM (2015) Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach. BMC Cardiovasc Disord 15:143. https://doi.org/10.1186/s12872-015-0137-7

    Article  PubMed  PubMed Central  Google Scholar 

  36. Granziera S, Cohen AT, Nante G, Manzato E, Sergi G (2015) Thromboembolic prevention in frail elderly patients with atrial fibrillation: a practical algorithm. J Am Med Dir Assoc 16(5):358–364. https://doi.org/10.1016/j.jamda.2014.12.008

    Article  PubMed  Google Scholar 

  37. Konrat C, Boutron I, Trinquart L, Auleley GR, Ricordeau P, Ravaud P (2012) Underrepresentation of elderly people in randomised controlled trials. The example of trials of 4 widely prescribed drugs. PLoS One 7(3):e33559. https://doi.org/10.1371/journal.pone.0033559

    Article  PubMed  PubMed Central  CAS  Google Scholar 

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Acknowledgements

We wish to acknowledge all the investigators of the NONAVASC registry for collecting data for the study, and also would like to thank Mr M. Gómez for his kind review of the final draft of the manuscript.

M. Camafort Babkowski, E. Rovira Daudí, E. Jarauta Simón, I. García Polo, J.C. Arévalo Lorido, J. Portillo Sánchez, I. Martínez Moreno, C. de la Guerra Acebal, C. Argüello Martín, SI. Aranda Sánchez, I. Novo Veleiro, M. Pena Seijo, F. Salgado Ordoñez, J.A. Vargas Hitos, J. González Moraleja, NR. Tobares Carrasco, P. Freixas Descarrega, I. Campodarve Botet, C. Fernández Capitán, LM. Palomar Rodríguez, AB. Gómez Belda, D. Chivite Guillén, M.A. Rico Corral, JL. Hernández Hernández, E. Coloma Bazán, X. Sobrino Martínez, J. Grandes Ibáñez, M. Martín Millán, R. Cuenca Acevedo, JB. Pérez Lorenz, A. de la Peña Fernández, G. López Castellanos, E. Montero Hernández, E. Calderón Sandubete, C. Lahoz Rallo, A. de los Santos Moreno, J.A. Martínez Muradas, J. Alfonso Megido, J.I. Cuende Melero, R. Cotos Cancas, JJ. Tamarit García, F. Bonilla Rovira, A. Epalza Bueno, M. Morales Conejo, L. Manzano Espinosa, S. Freire Castro, A. Rodríguez González, M. Menduiña Guillén, A. López Suárez, JF. Sánchez Muñoz- Torrero, M.D. Martín Escalante, JA. Ortiz Minuesa, J.C. Martínez-Acitores, M.B. Alonso Ortiz, D. Filella Agulló, H. Ágreda López, M. Romero Jiménez, ME. Fernández Pérez, J.L. Díaz Díaz, C. Pérez Bocanegra, R. Martínez Fernández, J.A. Nieto Rodríguez, J. Masferrer Serra, L. Mérida Rodrigo, J.M. Varela Aguilar, A. Mujal Martínez, L. Castilla Guerra, P. Castellanos Llauger, G. Tiberio López, E. Guevara Sierra, and J. Fernández Pardo.

Funding

The registry website was funded by a non-conditioned grant from Bayer Laboratories.

Author information

Authors and Affiliations

  1. Internal Medicine Department, University Hospital of La Princesa, Institute for Biomedical Research IIS-IPrincesa, C/Diego de León 62, 28006, Madrid, Spain

    Alejandra Gullón

  2. Internal Medicine Department, Geriatric Unit, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain

    Francesc Formiga

  3. Internal Medicine Department, University Hospital Miguel Servet, Zaragoza, Spain

    Jesús Díez-Manglano

  4. Internal Medicine Department, University Hospital of La Paz-Carlos III, Madrid, Spain

    José María Mostaza

  5. Internal Medicine Department, Hospital Vega Baja, Orihuela, Alicante, Spain

    José María Cepeda

  6. Internal Medicine Department, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain

    Antonio Pose

  7. Internal Medicine Department, Fundación Hospital Calahorra, Calahorra, La Rioja, Spain

    Jesús Castiella

  8. Internal Medicine Department, University Hospital of La Princesa, Madrid, Spain

    Carmen Suárez-Fernández

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  1. Alejandra Gullón
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  2. Francesc Formiga
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  4. José María Mostaza
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  6. Antonio Pose
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Consortia

the NONAVASC study group Vascular Risk Group of the Spanish Society of Internal Medicine

  • M. Camafort Babkowski
  • , E. Rovira Daudí
  • , E. Jarauta Simón
  • , I. García Polo
  • , J. C. Arévalo Lorido
  • , J. Portillo Sánchez
  • , I. Martínez Moreno
  • , C. de la Guerra Acebal
  • , C. Argüello Martín
  • , S. I. Aranda Sánchez
  • , I. Novo Veleiro
  • , M. Pena Seijo
  • , F. Salgado Ordoñez
  • , J. A. Vargas Hitos
  • , J. González Moraleja
  • , N. R. Tobares Carrasco
  • , P. Freixas Descarrega
  • , I. Campodarve Botet
  • , C. Fernández Capitán
  • , L. M. Palomar Rodríguez
  • , A. B. Gómez Belda
  • , D. Chivite Guillén
  • , M. A. Rico Corral
  • , J. L. Hernández Hernández
  • , E. Coloma Bazán
  • , X. Sobrino Martínez
  • , J. Grandes Ibáñez
  • , M. Martín Millán
  • , R. Cuenca Acevedo
  • , J. B. Pérez Lorenz
  • , A. de la Peña Fernández
  • , G. López Castellanos
  • , E. Montero Hernández
  • , E. Calderón Sandubete
  • , C. Lahoz Rallo
  • , A. de los Santos Moreno
  • , J. A. Martínez Muradas
  • , J. Alfonso Megido
  • , J. I. Cuende Melero
  • , R. Cotos Cancas
  • , J. J. Tamarit García
  • , F. Bonilla Rovira
  • , A. Epalza Bueno
  • , M. Morales Conejo
  • , L. Manzano Espinosa
  • , S. Freire Castro
  • , A. Rodríguez González
  • , M. Menduiña Guillén
  • , A. López Suárez
  • , J. F. Sánchez Muñoz-Torrero
  • , M. D. Martín Escalante
  • , J. A. Ortiz Minuesa
  • , J. C. Martínez-Acitores
  • , M. B. Alonso Ortiz
  • , D. Filella Agulló
  • , H. Ágreda López
  • , M. Romero Jiménez
  • , M. E. Fernández Pérez
  • , J. L. Díaz Díaz
  • , C. Pérez Bocanegra
  • , R. Martínez Fernández
  • , J. A. Nieto Rodríguez
  • , J. Masferrer Serra
  • , L. Mérida Rodrigo
  • , J. M. Varela Aguilar
  • , A. Mujal Martínez
  • , L. Castilla Guerra
  • , P. Castellanos Llauger
  • , G. Tiberio López
  • , E. Guevara Sierra
  •  & J. Fernández Pardo

Corresponding author

Correspondence to Alejandra Gullón.

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Conflict of interest

None of the authors have had any relationship with industry and financial associations that might pose a conflict of interest with the manuscript.

Statements on human and animal rights

The study is approved by the appropriate institutional research ethics committee. All procedures performed in the study involving human participants are in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

A written informed consent was obtained from all participants included in the study.

Additional information

The members of “The NONAVASC study group Vascular Risk Group of the Spanish Society of Internal Medicine” are listed in Ackowledgements section.

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Gullón, A., Formiga, F., Díez-Manglano, J. et al. Influence of frailty on anticoagulant prescription and clinical outcomes after 1-year follow-up in hospitalised older patients with atrial fibrillation. Intern Emerg Med 14, 59–69 (2019). https://doi.org/10.1007/s11739-018-1938-3

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