Higher mortality in frail elderly with atrial fibrillation using oral anticoagulants

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Abstract Background/Introduction Frail older persons with falls are often undertreated for atrial fibrillation (AF) due to fear of bleeding complications of oral anticoagulants (OAC). However, the safety of OAC use in frail elderly with AF and falls is not investigated extensively. Purpose The aim of the study was to investigate whether frail older persons with falls and OAC for AF have more bleeding complications than patients without OAC and to investigate the association between frailty, OAC therapy (including bleeding complications), and mortality. Methods This observational study included frail patients aged 65 years or older who were evaluated for falls between November 2011 and December 2019. Patients using OAC for AF were compared with similar patients without using OAC. Primary outcomes were death, major bleeding and intracranial bleeding. Secondary outcomes were frailty measured by the Frailty Index and cause of death. Results Of the 645 included patients, 132 had AF and used OAC. Patients with AF were more often severely frail (67% vs. 47%, p<0.001) and had a higher mortality during follow up (39% vs. 27%, p=0.005). Patients using OAC had a higher mortality risk compared to the patients without OAC (crude analysis Hazard Ratio (HR) 1.7 (95% confidence interval (CI) 1.3–2.4), p=0.001; after adjustment for age, gender, and frailty index HR 1.4 (95% CI 0.99–1.9) p=0.056). No differences were found in the incidence of major bleedings (10% vs. 7%, p=0.204) or intracranial bleedings (5% vs. 4%, p=0.739) in both groups. The causes of death were similar in both groups, also the incidence of fatal bleedings did not differ (5% vs 7%, p=0.758). Conclusions Elderly with falls and AF using OAC are frailer and have a tendency to a higher mortality risk than patients without AF. These frail elderly patients with falls had no more bleeding complications during OAC treatment than comparable patients without OAC. Therefore, withholding OAC out of fear for major bleeding complications is not justified. It is unclear why elderly persons with AF and OAC are frailer and die sooner, since the incidence of major bleedings and fatal bleedings is equal. Further research should focus why older frail persons with AF are more prone to die. Funding Acknowledgement Type of funding sources: None.

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