In older patients with atrial fibrillation (AF) and cognitive impairment, anticoagulation was associated with more major bleeding episodes and death than no anticoagulation, a study shows. Patients with frailty showed a similar trend that did not reach statistical significance.
At Massachusetts and Georgia clinics in 2016–18, 1,244 individuals with AF who were 65 years of age or older and a CHA2DS2-VASc score of 2 or more were recruited and followed until 2020. Based on frailty status and cognitive function at baseline, these outcomes were identified using hazard ratios of anticoagulation: “The average age was 75.5 (± 7.1) years, 49% were women, and 86% were prescribed oral anticoagulants. At baseline, 528 (42.4%) participants were cognitively impaired and 172 (13.8%) were frail. The adjusted hazard ratios of anticoagulation for the composite of major bleeding or death were 2.23 (95% confidence interval: 1.08–4.61) among cognitively impaired individuals and 0.94 (95% confidence interval: 0.49–1.79) among cognitively intact individuals (P for interaction = 0.08). Adjusted hazard ratios for anticoagulation were 1.84 (95% confidence interval: 0.66–5.13) among frail individuals and 1.39 (95% confidence interval: 0.84–2.40) among not frail individuals (P for interaction = 0.67).”
Editorial: “The findings suggest that in older patients with significant cognitive impairment, the potential harm of anticoagulation may exceed—by a substantial margin—the potential benefit,” writes an editorialist. “Similarly, the findings raise concern that anticoagulation may not be associated with a net clinical benefit for frail older patients with AF. These results clearly challenge the existing paradigm that endorses anticoagulation for virtually all older men with AF and a CHA2DS2-VASc score of 2 or higher and all older women with a CHA2DS2-VASc score of 3 or higher in the absence of prohibitive bleeding risk or other contraindications. Nonetheless, while the findings are provocative and may be incorporated into shared decision-making in selected cases, they are largely hypothesis-generating and limited by a lack of randomization, a modest sample size, and the relative homogeneity of the study population. In summary, while additional studies are clearly needed to replicate or refute these findings, it would be premature to revise the paradigm, update the guidelines, or translate the results of this study into the routine care of older adults with AF.”