Physical, cognitive, and psychosocial conditions in relation to anticoagulation satisfaction among elderly adults with atrial fibrillation: The SAGE-AF study.

Successful anticoagulation is critical for stroke prevention in adults with atrial fibrillation (AF). Anticoagulation satisfaction is a key indicator of treatment success. While physical, cognitive, and psychosocial limitations are common in elderly AF patients, their associations with anticoagulation satisfaction are unknown. Examine whether anticoagulation satisfaction differs among AF patients with and without physical, cognitive, and psychosocial conditions. The study comprised AF patients greater than or equal to 65 years old who were prescribed an oral anticoagulant (warfarin 57%; direct oral anticoagulant [DOAC] 43%). Frailty, cognitive function, social support, depressive symptoms, vision, hearing, and anxiety were assessed using validated measures. Anticoagulation satisfaction was measured using the anticlot treatment scale. Participants (n = 1037, 50% female) were on average 76 years old. The following conditions were prevalent: frailty (14%), cognitive impairment (42%), social isolation (13%), vision impairment (35%), hearing impairment (36%), depression (29%), and anxiety (24%). Average anticlot treatment burden scale was 55 out of 60 (lower burden scales indicating higher perceived burden). Patients with high perceived burden were older, more likely to be female, and receive warfarin. After adjusting for confounders, visual impairment (adjusted odds ratio [95% confidence interval]: 1.7 [1.2-2.4]), depressive symptoms (2.4 [1.6-3.7]), and anxiety (1.8 [1.2-2.7]) were significantly associated with high perceived burden. Different conditions were associated with high perceived burden in warfarin vs DOAC users. Physical, cognitive, and psychosocial limitations are prevalent and associated with high perceived anticoagulation burden among elderly AF adults. These conditions merit consideration in anticoagulation prescribing.

Wang W ，Saczynski J ，Lessard D ，Mailhot T ，Barton B ，Waring ME ，Sogade F ，Hayward R ，Helm R ，McManus DD ... -  《-》

Geriatric Elements and Oral Anticoagulant Prescribing in Older Atrial Fibrillation Patients: SAGE-AF.

Oral anticoagulants are the cornerstone of stroke prevention in high-risk patients with atrial fibrillation (AF). Geriatric elements, such as cognitive impairment and frailty, commonly occur in these patients and are often cited as reasons for not prescribing oral anticoagulants. We sought to systematically assess geriatric impairments in patients with AF and determine whether they were associated with oral anticoagulant prescribing. Cross-sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) prospective cohort study. Multicenter study with site locations in Massachusetts and Georgia that recruited participants from cardiology, electrophysiology, and primary care clinics from 2016 to 2018. Participants with AF age 65 years or older, CHA2 DS2 -VASc (congestive heart failure; hypertension; aged ≥75 y [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65-74; female sex) score of 2 or higher, and no oral anticoagulant contraindications (n = 1244). A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Oral anticoagulant use was abstracted from the medical record. A total of 1244 participants (mean age = 76 y; 49% female; 85% white) were enrolled; 42% were cognitively impaired, 14% frail, 53% pre-frail, 12% socially isolated, and 29% had depressive symptoms. Oral anticoagulants were prescribed to 86% of the cohort. Oral anticoagulant prescribing did not vary according to any of the geriatric elements (adjusted odds ratios [ORs] for oral anticoagulant prescribing and cognitive impairment: OR = .75; 95% confidence interval [CI] = .51-1.09; frail OR = .69; 95% CI = .35-1.36; social isolation OR = .90; 95% CI = .52-1.54; depression OR = .79; 95% CI = .49-1.27; visual impairment OR = .98; 95% CI = .65-1.48; and hearing impairment OR = 1.05; 95% CI = .71-1.54). Geriatric impairments, particularly cognitive impairment and frailty, were common in our cohort, but treatment with oral anticoagulants did not differ by impairment status. These geriatric impairments are commonly cited as reasons for not prescribing oral anticoagulants, suggesting that prescribers may either be unaware or deliberately ignoring the presence of these factors in clinical settings. J Am Geriatr Soc 68:147-154, 2019.

Saczynski JS ，Sanghai SR ，Kiefe CI ，Lessard D ，Marino F ，Waring ME ，Parish D ，Helm R ，Sogade F ，Goldberg R ，Gurwitz J ，Wang W ，Mailhot T ，Bamgbade B ，Barton B ，McManus DD ... -  《-》

Frailty, Cognitive Impairment, and Anticoagulation Among Older Adults with Nonvalvular Atrial Fibrillation.

Oral anticoagulation (OAC) is challenging in older patients with nonvalvular atrial fibrillation (NVAF) who are often frail and have cognitive impairment. We examined the characteristics of older NVAF patients associated with higher odds of physical and cognitive impairments. We also examined if these high-risk patients have different OAC prescribing patterns and their satisfaction with treatment because it may impact optimal management of their NVAF. The patients in the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF study cohort 2016-2018) had NVAF, were aged 65 and older, and eligible for the receipt of OAC. Measures included frailty (Fried Frailty scale), cognitive impairment (Montreal Cognitive Assessment Battery), OAC prescribing and type (direct oral anticoagulant [DOAC] or vitamin K antagonist [VKA]), depressive symptoms (Patient Health Questionnaire-9), bleeding, stroke risk, and treatment benefit (Anti-Clot Treatment Scale). Patients (n = 1,244) were 49% female, aged 76 (standard deviation = 7) years. A total of 14% were frail, and 42% had cognitive impairment. Frailty and cognitive impairment co-occurred in 9%. Odds of having both impairments versus none were higher with depression (odds ratio [OR] = 4.62; 95% confidence interval [CI] = 2.59-8.26), older age (OR = 1.56; 95% CI = 1.29-1.88), lower education (OR = 3.81; 95%CI = 2.13-6.81), race/ethnicity other than non-Hispanic White (OR = 7.94; 95% CI = 4.34-14.55), bleeding risk (OR = 1.43; 95% CI = 1.12-1.81), and stroke risk (OR = 1.35; 95% CI = 1.13-1.62). OAC prescribing was not associated with CI and frailty status. Among patients taking OACs (85%), those with both impairments were more likely to take DOAC than VKA (OR = 1.69; 95% CI = 1.01-2.80). Having both impairments (OR = 1.87; 95% CI = 1.08-3.27) or cognitive impairment (OR = 1.56; 95% CI = 1.09-2.24) was associated with higher odds of reporting lower treatment benefit. In a large cohort of older NVAF patients, half were frail or cognitively impaired, and 9% had both impairments. We highlight the characteristics of patients who may benefit from cognitive and physical function screenings to maximize treatment and enhance prognosis. Finally, the co-occurrence of impairment was associated with low perceived benefit of treatment that may impede optimal management.

Mailhot T ，McManus DD ，Waring ME ，Lessard D ，Goldberg R ，Bamgbade BA ，Saczynski JS ... -  《-》

Prescription Patterns and Outcomes of Patients With Atrial Fibrillation Treated With Direct Oral Anticoagulants and Warfarin: A Real-World Analysis.

Kattoor AJ ，Pothineni NV ，Goel A ，Syed M ，Syed S ，Paydak H ，Mehta JL ... -  《-》

The Effect of Bleeding Risk and Frailty Status on Anticoagulation Patterns in Octogenarians With Atrial Fibrillation: The FRAIL-AF Study.

Older adults are at increased risk of atrial fibrillation (AF), its thromboembolic complications, and bleeding. A significant percentage of octogenarians do not receive anticoagulation therapy. The objective of this study was to investigate the effect of thromboembolic risk, bleeding risk, and frailty on the anticoagulation status of octogenarians hospitalized with AF. A cross-sectional study was conducted in 682 hospitalized patients aged 80 years and older with AF or atrial flutter in Montreal, Québec. Consumption of warfarin or a new oral anticoagulant was documented. Medical record data were used to determine each patient's frailty status using the Clinical Frailty Scale (CFS) and to evaluate the risk of stroke (CHADS2 [Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack]) and bleeding (HAS-BLED [Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years) Drugs/alcohol concomitantly]). Univariable and multivariable logistic regression analyses were used to examine the effect of frailty status and the risk of stroke and bleeding on the probability of receiving anticoagulation therapy. Seventy percent of octogenarians with AF received anticoagulation therapy (n = 475). A high risk of stroke (CHADS2 = 3 compared with CHADS2 = 1, odds ratio [OR], 3.58; 95% confidence interval [CI], 1.09-11.77), and the absence of severe frailty (CFS < 7; OR, 3.41; 95% CI, 1.84-6.33) were independently associated with anticoagulant use in multivariable analyses. A high risk of bleeding (HAS-BLED score ≥ 3; OR, 0.33; 95% CI, 0.12-0.86) was associated with the absence of anticoagulation. Our study suggests a higher prevalence of appropriate anticoagulation among octogenarians with AF than reported in previous studies. Further work is needed to develop and disseminate tools to optimize the use of anticoagulants in this high-risk population.

Lefebvre MC ，St-Onge M ，Glazer-Cavanagh M ，Bell L ，Kha Nguyen JN ，Viet-Quoc Nguyen P ，Tannenbaum C ... -  《-》