Association of frailty and cognitive impairment with benefits of oral anticoagulation in patients with atrial fibrillation

• Published in: The American heart journal Vol. 211; pp. 77 - 89
• Main Authors: Madhavan, Malini, Holmes, DaJuanicia N., Piccini, Jonathan P., Ansell, Jack E., Fonarow, Gregg C., Hylek, Elaine M., Kowey, Peter R., Mahaffey, Kenneth W., Thomas, Laine, Peterson, Eric D., Chan, Paul, Allen, Larry A., Gersh, Bernard J.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-05-2019; Elsevier Limited
• Subjects: Administration, Oral; Age; Aged; Aged, 80 and over; Anticoagulants; Anticoagulants - therapeutic use; Atrial Fibrillation - complications; Atrial Fibrillation - drug therapy; Atrial Fibrillation - psychology; Bleeding; Cardiac arrhythmia; Central nervous system; Cerebral infarction; Cognitive ability; Cognitive Dysfunction; Dementia; Demographics; Embolism; Embolisms; Enrollments; Female; Fibrillation; Follow-Up Studies; Frailty; Geriatrics; Health risks; Heart failure; Humans; Impairment; Ischemia; Male; Mortality; Myocardial infarction; Patients; Regression analysis; Risk Factors; Stroke; Stroke - etiology; Stroke - prevention & control; Transient ischemic attack; Treatment Outcome; United States > US
• ISSN: 0002-8703; 1097-6744
• DOI: 10.1016/j.ahj.2019.01.005

The incidence of cognitive impairment and frailty increase with age and may impact both therapy and outcomes in atrial fibrillation (AF).
We examined the prevalence of clinically recognized cognitive impairment and frailty (as defined by the American Geriatric Society Criteria) in the Outcomes Registry for Better Informed Care in AF (ORBIT AF) and associated adjusted outcomes via multivariable Cox regression. The interaction between cognitive impairment and frailty and oral anticoagulation (OAC) in determining outcomes was examined.
Among 9749 patients with AF [median (IQR) age 75 (67–82) y, 57% male], cognitive impairment and frailty was identified in 293 (3.0%) and 575 (5.9%) patients respectively. Frail patients (68 vs 77%, P < .001) and those with cognitive impairment (70 vs 77%, P = .006) were both less likely to receive an OAC. Both cognitive impairment [HR (95% CI) 1.34 (1.05–1.72), P = .0198] and frailty [HR 1.29 (1.08–1.55), P = .0060] were associated with increased risk of death. Cognitive impairment and frailty were not associated with stroke/transient ischemic attack (TIA) or major bleeding. In multivariable analysis, there was no interaction between OAC use and cognitive impairment or frailty in their associations with mortality, major bleeding and a composite end point of stroke, non-central nervous system systemic embolism, TIA, myocardial infarction or cardiovascular death.
Those with cognitive impairment or frailty in AF had higher predicted risk for stroke and higher observed mortality, yet were less likely to be treated with OAC. Despite this, the benefits of OAC were similar in patients with and without cognitive impairment or frailty.