Multimorbidity, frailty and malnutrition: moving beyond traditional risk factors for risk assessment in atrial fibrillation. The Murcia Atrial Fibrillation Project II
Authors: Rivera-Caravaca J M , Zazo-Luengo B , Martinez-Montesinos L , Lopez-Galvez R , Garcia-Tomas L , Lip G Y H , Marin F , Roldan V 
Published: October 2022

Abstract

Background
The management of atrial fibrillation (AF) has evolved over the last decade with a more towards a more multidisciplinary, integrated and holistic approach. However, several conditions that may influence the prognosis and management of AF patients are still under-recognised.

Purpose
Our aim was to investigate if multimorbidity, frailty and malnutrition are associated with the risk of worse clinical outcomes in patients with recent diagnosis of AF starting oral anticoagulation (OAC) therapy.

Methods
Prospective cohort study including outpatients newly diagnosed with AF starting vitamin K antagonist (VKA) therapy from July 1, 2016 to June 30, 2018. Morbidity was assessed with the crude number of comorbidities. Frailty was assessed with the Clinical Frailty Scale (CFS). Nutrition status was assessed with the Controlling Nutritional Status (CONUT) score. During 2-years of follow-up, we recorded all ischemic strokes/transient ischemic attacks (TIAs), major bleeds (according to the 2005 International Society on Thrombosis and Haemostasis criteria), and all-cause deaths.

Results
We included 1050 patients (540 [51.4%] females, median age 77 [IQR 70–83] years), with median CHA2DS2-VASc of 4 [IQR 3–5] and median HAS-BLED of 2 [IQR 2–3]. The median crude number of comorbidities was 3 [IQR 2–5], whereas the median CFS and CONUT score were 2 [IQR 2–3] and 2 [IQR 1–3], respectively. The crude number of comorbidities, CFS and CONUT score demonstrated a significant positive correlation (p&lt;0.001 for all correlations). After adjusting for several risk factors (age, sex, hypertension, diabetes, previous stroke, vascular disease, heart failure, chronic kidney disease, dyslipidemia, sleep apnoea, hepatic disease, and cancer), the CFS was independently associated with major bleeding (adjusted HR 1.25, 95% CI 1.07–1.45) and all-cause mortality (aHR 1.20, 95% CI 1.09–1.32). The crude number of comorbidities (aHR 1.30, 95% CI 1.14–1.49) was also associated with major bleeding, and the CONUT score (aHR 1.25, 95% CI 1.15–1.35) was associated with all-cause mortality. Any frailty degree (i.e CFS ≥5) was associated with a 3-fold higher risk of major bleeding (aHR 3.04, 95% CI 1.67–5.52) and a 2-fold higher risk of death (aHR 2.04, 95% CI 1.39–3.01), whereas the moderate/severe malnutrition (i.e. CONUT ≥5) was an independent risk factor for ischemic stroke/TIA and (aHR 2.25, 95% CI 1.11–4.56) and death (aHR 3.21, 95% CI 2.14–4.83) (Figures 1 and 2).

Conclusions
Frailty and malnutrition are important risk factors for bleeding, stroke and mortality in AF. The frailty degree and nutritional status should be assessed in all AF patients in order to address them properly and provide a truly integrated management.

Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the Spanish Ministry of Economy, Industry, and Competitiveness, through the Instituto de Salud Carlos III after independent peer review (research grant: PI17/01375 co-financed by the European Regional Development Fund)