Effectiveness and safety of direct oral anticoagulation vs. warfarin in frail patients with atrial fibrillation

Management of Atrial Fibrillation in Elderly Patients: A Whole New Ballgame?

Atrial fibrillation (AF) is the most prevalent sustained supraventricular arrhythmia, particularly in older adults, with its incidence increasing dramatically with age. This condition is a significant contributor to morbidity and mortality, being closely linked to an elevated risk of heart failure, ischemic stroke, systemic thromboembolism, and dementia. The complexities of managing AF in the elderly arise from age-related physiological changes, comorbidities, frailty, and the challenges of polypharmacy. Therapeutic strategies must balance efficacy and safety, tailoring interventions to the individual's health status, life expectancy, and personal preferences. This review explores the latest evidence-based approaches to managing AF in elderly patients, focusing on the nuanced application of rate and rhythm control strategies, anticoagulation, and emerging insights into the relationship between AF and cognitive impairment.

Profiles of Geriatric Syndromes and Resources in Older Patients with Atrial Fibrillation

Objective: Older patients with nonvalvular atrial fibrillation (AF) are at high risk for frailty and geriatric syndromes (GSs), which modulate their individual prognosis and are therefore relevant for further management. Because few studies have evaluated the geriatric profile of older AF patients, this secondary analysis aims to further characterize the patterns of GSs and geriatric resources (GRs) in AF patients and their association with anticoagulation use. Methods: Data from 362 hospitalized patients aged 65 years and older with AF (n = 181, 77.8 ± 5.8 years, 38% female) and without AF (non-AF [NAF]; n = 181, 77.5 ± 5.9 years, 40% female) admitted to an internal medicine and nephrology ward of a large university hospital in Germany were included. All patients underwent usual care plus a comprehensive geriatric assessment (CGA) including calculation of the Multidimensional Prognostic Index (MPI) and collection of 17 GSs and 10 GRs. Patients were followed up by telephone 6 and 12 months after discharge to collect data on their health status. Results: The mean MPI score of 0.47 indicated an average risk of poor outcome, and patients with AF had a significantly higher MPI than those without AF (p = 0.040). After adjustment for chronological age, biological sex, Cumulative Illness Rating Scale (CIRS) for relevant chronic diagnoses and MPI as a proxy for biological age, AF patients had significantly more mnestic resources (63.5% vs. 33.1%, p < 0.001), a tendency for less age-appropriate living conditions (56.4% vs. 72.9%, p = 0.051) and more sensory impairment (78.5% vs. 52.5%, p < 0.001) than NAF patients. They also had a higher number of GSs (p = 0.046). AF patients on oral anticoagulants (OACs, n = 91) had less age-appropriate living conditions (48.4% vs. 64.4%, p < 0.05) and mnestic resources (36.3% vs. 54.4%, p < 0.01), but more emotional resources (80.2% vs. 65.6%, p < 0.05) and chronic pain (56% vs. 40%, p < 0.05) than patients without OACs (n = 90). Overall, mortality at 1 year was increased in patients with a higher MPI (p < 0.009, adjusted for age, sex and CIRS), with a diagnosis of AF (p = 0.007, adjusted for age, sex, CIRS and MPI), with of male sex (p = 0.008, adjusted for age, CIRS and MPI) and those with AF and treated with hemodialysis (p = 0.022, compared to AF patients without dialysis treatment). Conclusions: Patients with AF and patients with AF and OACs show differences in their multidimensional frailty degree as well as GR and GS profiles compared to patients without AF or with AF not treated with OACs. Mortality after 1 year is increased in AF patients with a higher MPI and dialysis, independently from OAC use and overall burden of chronic disease as assessed per CIRS. GRs and GSs, especially age-appropriate living conditions, emotional resources, sensory impairment and chronic pain, can be considered as factors that may modify the individual impact of frailty, underscoring the relevance of these parameters in the management of older patients.

Direct Oral Anticoagulants in Special Patient Populations

Anticoagulants are a cornerstone of treatment in atrial fibrillation. Nowadays, direct oral anticoagulants (DOACs) are extensively used for this condition in developed countries. However, DOAC treatment may be inappropriate in certain patient populations, such as: patients with chronic kidney disease in whom DOAC concentrations may be dangerously elevated; frail elderly patients with an increased risk of falls; patients with significant drug-drug interactions (DDI) affecting either DOAC concentration or effect; patients at the extremes of body mass in whom an "abnormal" volume of distribution may result in inappropriate drug concentrations; patients with recurrent stroke reflecting an unusually high thromboembolic tendency; and, lastly, patients who experience major hemorrhage on an anticoagulant and in whom continued anticoagulation is deemed necessary. Herein we provide a fictional case-based approach to review the recommendations for the use of DOACs in these special patient populations.