Frailty and anticoagulants in older subjects with atrial fibrillation: The EUROSAF study

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.