Net Clinical Benefit of Oral Anticoagulation Among Frail Patients With Atrial Fibrillation: Nationwide Cohort Study

Mette Søgaard*, Martin Jensen, Anette Arbjerg Højen, Torben Bjerregaard Larsen, Gregory Y. H. Lip, Anne Gulbech Ording, Peter Brønnum Nielsen

*Corresponding author for this work

Research output: Contribution to journalJournal articleResearchpeer-review

Abstract

BACKGROUND: Frail people with atrial fibrillation are often undertreated with oral anticoagulants (OACs), and evidence for the net clinical benefit (NCB) of OAC is sparse. We, therefore, examined the risk of thromboembolic events, major bleeding, and NCB of anticoagulation treatment.

METHODS: This was a nationwide cohort study including frail patients aged with incident atrial fibrillation between 2013 and 2018. Patients were categorized according to OAC treatment exposure. One-year risks of thromboembolic events and major bleeding were ascertained where death was treated as a competing risk. The NCB of anticoagulation was assessed by a bivariate trade-off between thromboembolism and bleeding.

RESULTS: We identified 36 223 frail patients with atrial fibrillation (median age, 79 years; 50.5% female), of whom 61.8% started OAC therapy, while 38.2% were untreated despite indication for stroke prevention. At 1 year, the risk of thromboembolic events was 2.1% (95% CI, 1.8%-2.3%) among patients not receiving OAC versus 1.5% (95% CI, 1.4%-1.7%) in patients with OAC. The bleeding risk was 3.2% (95% CI, 2.9%-3.5%) among patients without OAC versus 3.5% (95% CI, 3.2%-3.8%) among anticoagulated patients. The NCB was 0.70% (95% CI, 0.32%-1.08%), suggesting a benefit of OAC treatment; however, the NCB declined with age and increasing frailty and was lowest among patients >75 years of age or with high frailty level.

CONCLUSIONS: Frail patients with atrial fibrillation are often untreated with OAC in routine clinical care despite an indication for stroke prevention. The NCB balancing thromboembolic events and major bleeding was in favor of anticoagulation but decreased with advancing age and increasing frailty.

Original languageEnglish
JournalStroke
Volume55
Issue number2
Pages (from-to)413-422
Number of pages10
ISSN0039-2499
DOIs
Publication statusPublished - Feb 2024

Keywords

  • Aged
  • Anticoagulants/adverse effects
  • Atrial Fibrillation/complications
  • Cohort Studies
  • Female
  • Frail Elderly
  • Frailty/epidemiology
  • Hemorrhage/chemically induced
  • Humans
  • Male
  • Stroke/epidemiology
  • Thromboembolism/epidemiology
  • thromboembolism
  • frailty
  • atrial fibrillation
  • cohort studies
  • hemorrhage

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