Frailty and anticoagulants in older subjects with atrial fibrillation: the EUROSAF study
Authors: Pilotto Alberto , Veronese Nicola , Polidori Maria Cristina , Strandberg Timo , Topinkova Eva , Cruz-Jentoft Alfonso J , Custodero Carlo , Barbagallo Mario , Maggi Stefania ,   the EUROSAF Study Investigators, Ferri Alberto , Argusti Alessandra , Gandolfo Federica , Musacchio Clarissa , Quispe Guerrero Katerin Leslie , Pilotto Alberto , Custodero Carlo , Solfrizzi Vincenzo , Sabbà Carlo , Polidori Maria Cristina , Verleysdonk Joshua , Noetzela Nico , Strandberg Timo , Rossinen Juhani , Pikkarainen Laura , Nieminen Tuomo , Topinkova Eva , Michalkova Helena , Madlova Pavla , Bautzka Lucie , Stefania  , Ferrara Nicola , Gioia Lucia , Iannicelli Anna Maria , Barbagallo Mario , Veronese Nicola , Di Bella Giovanna , Cacioppo Federica , Ruotolo Giovanni , Castagna Alberto , Roller-Wirnsberger Regina , Sebesta Christian , Lindner Sonja , Cruz-Jentoft Alfonso , Hernandez-Sanchez Luisa A , Lopez Jana Albeniz , Olaya-Loor Genesis Estefanıa , da Silva Pedro Marques , Gruner Heidi , Petermans Jean , Gillain Sophie , Jonart Veronique , Vyska Ondrej , Nakladal Jiri , Bielakova Katarina , Matejovska-Kubesova Hana , Enica Adrian , Roth Stephanie , Jacquet Benjamin , Curiale Vito , Berg Nicolas , Cimpeanu Livia Mirea , Verissimo Rafaela , Silva Leonor , Silva Luciana , Magalhães Pedro , Ioan Prada Gabriel , Marie Herghelegiu Anna , Raluca Nuta Catalina , Garmendia-Prieto Blanca , Lozano-Montoya Isabel , Jaramillo-Hidalgo Javier , Gomez-Pav Javier , Müller-Werdan Ursula , Werth Gordon , Rosada Adrian , Yilmaz Ozlem , Francesco Mattace-Raso Sena Geurkaş 
Published: September 2024

Abstract

Aims
Literature regarding anticoagulants in older people affected by atrial fibrillation (AF) is limited to retrospective studies, poorly considering the importance of multidimensional frailty. The main objective of this study is to evaluate in hospitalised older persons with AF the benefit/risk ratio of the anticoagulant treatments, considering the severity of frailty, determined by the multidimensional prognostic index (MPI).

Methods
In this European, multicentre, prospective study, older hospitalised patients (≥65 years) with non-valvular AF were followed-up for 12 months. Anticoagulants’ use at discharge ascertained using medical records. MPI was calculated using tools derived from comprehensive geriatric assessment, classifying participants in robust, pre-frail or frail. Mortality (primary outcome); vascular events, including ischemic heart disease or ischemic stroke, hemorrhagic stroke or gastrointestinal bleedings (secondary outcomes).

Results
2,022 participants (mean age 82.9 years; females 56.6%) were included. Compared with people not taking anticoagulants (n = 823), people using vitamin K antagonists (n = 450) showed a decreased risk of mortality (hazard ratio, HR = 0.74; 95% CI: 0.59–0.93), more pronounced in patients using direct oral anticoagulants (DOACs) (n = 749) (HR = 0.46; 95% CI: 0.37–0.57). Only people taking DOACs reported a significantly lower risk of vascular events (HR = 0.55; 95% CI: 0.31–0.97). The efficacy of DOACs was present independently from frailty status. The risk of gastrointestinal bleedings and hemorrhagic stroke did not differ based on the anticoagulant treatments and by MPI values.

Conclusions
Anticoagulant treatment, particularly with DOACs, was associated with reduced mortality in older people, without increasing the risk of hemorrhagic events, overall suggesting the importance of treating with anticoagulants older people with AF.