The Risk of Falling and Consequences of Falling in Patients with Atrial Fibrillation Receiving Different Types of Anticoagulant

Abstract

Objective

Our objective was to investigate the predictors of falls requiring a visit to the emergency department in patients with nonvalvular atrial fibrillation (AF) receiving different types of anticoagulants and to investigate the clinical consequences of falling in the same population.

Methods

A total of 1217 patients with nonvalvular AF from two institutions were retrospectively evaluated. Each patient underwent a physical examination, and clinical histories and medication profiles were taken from each patient at baseline.

Results

The median age of our cohort was 71 years; 52.3% were males, and 86.1% of patients were receiving anticoagulation at study baseline. The 5-year freedom-from-falling rate was 81.6%. The use and type of anticoagulation was not significantly associated with the risk of falling (P = 0.222), whereas higher Morse Fall Scale (MFS), CHA2DS2-VASC (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65–74 years, sex category), and HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly [> 65 years], drugs/alcohol concomitantly) scores were significantly associated with a higher hazard of the first fall in univariate analyses. In the multivariate Cox regression model, MFS, older age, osteoporosis, higher levels of high-density lipoprotein cholesterol, higher diastolic blood pressure, and use of amiodarone, diuretics, or short- and medium-acting benzodiazepines were mutually independent predictors of the first fall. Of 163 patients, 93 (57%) had a bone fracture during the fall. Type of anticoagulation significantly affected survival after the first fall (P < 0.001): patients inadequately anticoagulated with warfarin had worse survival rates, and patients receiving apixaban and dabigatran had the best survival rates after the first fall.

Conclusion

Older patients who had comorbidities and were taking amiodarone, diuretics, or short- or medium-acting benzodiazepines had the highest risk of falls. The type and quality of anticoagulation did not seem to affect the risk of falling but did significantly affect survival after the first fall.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

References

  1. 1.

    Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837–47.

    Article  Google Scholar 

  2. 2.

    Torstensson M, Hansen AH, Leth-Møller K, Jørgensen TS, Sahlberg M, Andersson C, et al. Danish register-based study on the association between specific cardiovascular drugs and fragility fractures. BMJ Open. 2015;5(12):e009522.

    Article  Google Scholar 

  3. 3.

    Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148–57.

  4. 4.

    Jansen S, Frewen J, Finucane C, de Rooij SE, van der Velde N, Kenny RA. AF is associated with self-reported syncope and falls in a general population cohort. Age Ageing. 2015;44(4):598–603.

    Article  Google Scholar 

  5. 5.

    Hung C-Y, Wu T-J, Wang K-Y, Huang J-L, Loh E-W, Chen Y-M, et al. Falls and atrial fibrillation in elderly patients. Acta Cardiologica Sinica. 2013;29(5):436–43.

    PubMed  PubMed Central  Google Scholar 

  6. 6.

    Jurin I, Lucijanic M, Sakic Z, Hulak Karlak V, Atic A, Maglicic A, et al. Patterns of anticoagulation therapy in atrial fibrillation: results from a large real-life single-center registry. Croat Med J. 2020;61(5):440–9.

    CAS  Article  Google Scholar 

  7. 7.

    Garwood CL, Corbett TL. Use of anticoagulation in elderly patients with atrial fibrillation who are at risk for falls. Ann Pharmacother. 2008;42(4):523–32.

    CAS  Article  Google Scholar 

  8. 8.

    Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardio-Thorac Surg. 2016;50(5):e1–88.

    Article  Google Scholar 

  9. 9.

    Malik AH, Yandrapalli S, Aronow WS, Panza JA, Cooper HA. Meta-analysis of direct-acting oral anticoagulants compared with warfarin in patients > 75 years of age. Am J Cardiol. 2019;123(12):2051–7.

    CAS  Article  Google Scholar 

  10. 10.

    Savarese G, Sartipy U, Friberg L, Dahlström U, Lund LH. Reasons for and consequences of oral anticoagulant underuse in atrial fibrillation with heart failure. Heart. 2018;104(13):1093–100.

    CAS  Article  Google Scholar 

  11. 11.

    Durham TA, Hassmiller Lich K, Viera AJ, Fine JP, Mukherjee J, Weinberger M, et al. Utilization of standard and target-specific oral anticoagulants among adults in the United Kingdom with incident atrial fibrillation. Am J Cardiol. 2017;120(10):1820–9.

    CAS  Article  Google Scholar 

  12. 12.

    Bo M, Sciarrillo I, Li Puma F, Badinella Martini M, Falcone Y, Iacovino M, et al. Effects of oral anticoagulant therapy in medical inpatients ≥ 65 years with atrial fibrillation. Am J Cardiol. 2016;117(4):590–5.

    CAS  Article  Google Scholar 

  13. 13.

    Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. 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. 2010;137(2):263–72.

    Article  Google Scholar 

  14. 14.

    Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. 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. 2010;138(5):1093–100.

    Article  Google Scholar 

  15. 15.

    Morse J, Morse R, Tylko S. Development of a scale to identify the fall-prone patient. Can J Aging. 1989;8:366–7.

    Article  Google Scholar 

  16. 16.

    Lucijanic M, Petrovecki M. Analysis of censored data. Biochemia medica. 2012;22(2):151–5.

    Article  Google Scholar 

  17. 17.

    Lucijanic M. Survival analysis in clinical practice: analyze your own data using an Excel workbook. Croat Med J. 2016;57(1):77–9.

    Article  Google Scholar 

  18. 18.

    Kojima T, Akishita M, Nakamura T, Nomura K, Ogawa S, Iijima K, et al. Polypharmacy as a risk for fall occurrence in geriatric outpatients. Geriatr Gerontol Int. 2012;12(3):425–30.

    Article  Google Scholar 

  19. 19.

    LaMori JC, Mody SH, Gross HJ, daCosta DM, Patel AA, Schein JR, et al. Burden of comorbidities among patients with atrial fibrillation. Ther Adv Cardiovasc Dis. 2013;7(2):53–62.

    Article  Google Scholar 

  20. 20.

    Jaspers Focks J, Brouwer MA, Wojdyla DM, Thomas L, Lopes RD, Washam JB, et al. Polypharmacy and effects of apixaban versus warfarin in patients with atrial fibrillation: post hoc analysis of the ARISTOTLE trial. BMJ. 2016;15(353):i2868.

    Article  Google Scholar 

  21. 21.

    Lip GY, Pan X, Kamble S, Kawabata H, Mardekian J, Masseria C, et al. Major bleeding risk among non-valvular atrial fibrillation patients initiated on apixaban, dabigatran, rivaroxaban or warfarin: a “real-world” observational study in the United States. Int J Clin Pract. 2016;70(9):752–63.

    CAS  Article  Google Scholar 

  22. 22.

    Noseworthy PA, Yao X, Shah ND, Gersh BJ. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants versus warfarin in patients with atrial fibrillation and valvular heart disease. Int J Cardiol. 2016;15(209):181–3.

    Article  Google Scholar 

  23. 23.

    Lip GY, Keshishian A, Kamble S, Pan X, Mardekian J, Horblyuk R, et al. Real-world comparison of major bleeding risk among non-valvular atrial fibrillation patients initiated on apixaban, dabigatran, rivaroxaban, or warfarin. A propensity score matched analysis. Thromb Haemost. 2016;116(5):975–86.

    PubMed  Google Scholar 

  24. 24.

    Sellers MB, Newby LK. Atrial fibrillation, anticoagulation, fall risk, and outcomes in elderly patients. Am Heart J. 2011;161(2):241–6.

    Article  Google Scholar 

  25. 25.

    Donzé J, Clair C, Hug B, Rodondi N, Waeber G, Cornuz J, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012;125(8):773–8.

    Article  Google Scholar 

  26. 26.

    Lucijanic M, Jurin I, Jurin H, Lucijanic T, Starcevic B, Skelin M, et al. Patients with higher body mass index treated with direct/novel oral anticoagulants (DOAC/NOAC) for atrial fibrillation experience worse clinical outcomes. Int J Cardiol. 2020;15(301):90–5.

    Article  Google Scholar 

  27. 27.

    Namba S, Yamaoka-Tojo M, Kakizaki R, Nemoto T, Fujiyoshi K, Hashikata T, et al. Effects on bone metabolism markers and arterial stiffness by switching to rivaroxaban from warfarin in patients with atrial fibrillation. Heart Vessels. 2017;32(8):977–82.

    Article  Google Scholar 

  28. 28.

    Lutsey PL, Norby FL, Ensrud KE, MacLehose RF, Diem SJ, Chen LY, et al. Association of anticoagulant therapy with risk of fracture among patients with atrial fibrillation. JAMA Intern Med. 2019;180(2):245–53.

    Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Marko Lucijanić.

Ethics declarations

Funding

No sources of funding were used to conduct this study or prepare this manuscript.

Conflict of interest

IJ and TL have received speaker honoraria from Boehringer Ingelheim. IH has received speaker honoraria from Boehringer Ingelheim, Pfizer, and Bayer. Marko Lucijanić, Vedran Radonić, Jelena Lucijanić, Stjepan Mesarov, and Nikola Zagorec have no conflicts of interest that are directly relevant to the content of this article

Ethics approval

This study was approved by the relevant institutional review boards.

Consent to participate

Not applicable as this was a retrospective study.

Consent for publication

Not applicable.

Availability of data and material

Data are available on reasonable request.

Code availability

Not applicable as commercial statistical software was used.

Author contributions

IJ, ML, and IH conceptualized the study and drafted the manuscript. ML performed statistical analysis. All authors participated in data acquisition and interpretation, critical revision of the manuscript, and final approval of the submitted version. All authors agree to be accountable for all aspects of the work.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Jurin, I., Lucijanić, M., Radonić, V. et al. The Risk of Falling and Consequences of Falling in Patients with Atrial Fibrillation Receiving Different Types of Anticoagulant. Drugs Aging (2021). https://doi.org/10.1007/s40266-021-00843-9

Download citation