Risk scores and geriatric profile: can they really help us in anticoagulation decision making among older patients suffering from atrial fibrillation?

Frédéric Maes, Olivia Dalleur, Séverine Henrard, Dominique Wouters, Christophe Scavée, Anne Spinewine, Benoit Boland, Frédéric Maes, Olivia Dalleur, Séverine Henrard, Dominique Wouters, Christophe Scavée, Anne Spinewine, Benoit Boland

Abstract

Objectives: Anticoagulation for the prevention of cardio-embolism is most frequently indicated but largely underused in frail older patients with atrial fibrillation (AF). This study aimed at identifying characteristics associated with anticoagulation underuse.

Methods: A cross-sectional study of consecutive geriatric patients aged ≥75 years, with AF and clear anticoagulation indication (CHADS₂ [Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack] ≥2) upon hospital admission. All patients benefited from a comprehensive geriatric assessment. Their risks of stroke and bleeding were predicted using CHADS₂ and HEMORR2HAGES (Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age >75 years), Reduced platelet count or function, Rebleed risk, Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, and Stroke) scores, respectively.

Results: Anticoagulation underuse was observed in 384 (50%) of 773 geriatric patients with AF (median age 85 years; female 57%, cognitive disorder 33%, nursing home 20%). No geriatric characteristic was found to be associated with anticoagulation underuse. Conversely, anticoagulation underuse was markedly increased in the patients treated with aspirin (odds ratio [OR] [95% confidence interval]: 5.3 [3.8; 7.5]). Other independent predictors of anticoagulation underuse were ethanol abuse (OR: 4.0 [1.4; 13.3]) and age ≥90 years (OR: 2.0 [1.2; 3.4]). Anticoagulation underuse was not inferior in patients with a lower bleeding risk and/or a higher stroke risk and underuse was surprisingly not inferior either in the AF patients who had previously had a stroke.

Conclusion: Half of this geriatric population did not receive any anticoagulation despite a clear indication, regardless of their individual bleeding or stroke risks. Aspirin use is the main characteristic associated with anticoagulation underuse.

Keywords: anticoagulation; antiplatelet therapy; atrial fibrillation; geriatric medicine; under-prescribing.

References

    1. Cherubini A, Corsonello A, Lattanzio F. Underprescription of beneficial medicines in older people: causes, consequences and prevention. Drugs Aging. 2012;29(6):463–475.
    1. Monte S, Macchia A, Pellegrini F, et al. Antithrombotic treatment is strongly underused despite reducing overall mortality among high-risk elderly patients hospitalized with atrial fibrillation. Eur Heart J. 2006;27(18):2217–2223.
    1. Frewen J, Finucane C, Cronin H, et al. Atrial fibrillation is under recognised and inappropriately treated in older adults: cross-sectional findings from the Irish Longitudinal study on Ageing (TILDA) Age Ageing. 2013;42(suppl 2):ii4.
    1. Pugh D, Pugh J, Mead GE. Attitudes of physicians regarding anticoagulation for atrial fibrillation: a systematic review. Age Ageing. 2011;40(6):675–683.
    1. Ogilvie IM, Newton N, Welner SA, Cowell W, Lip GY. Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med. 2010;123(7):638–645.e4.
    1. Brass LM, Krumholz HM, Scinto JD, Mathur D, Radford M. Warfarin use following ischemic stroke among Medicare patients with atrial fibrillation. Arch Intern Med. 1998;158(19):2093–2100.
    1. Flaker GC, McGowan DJ, Boechler M, Fortune G, Gage B. Underutilization of antithrombotic therapy in elderly rural patients with atrial fibrillation. Am Heart J. 1999;137(2):307–312.
    1. Lau E, Bungard TJ, Tsuyuki RT. Stroke prophylaxis in institutionalized elderly patients with atrial fibrillation. J Am Geriatr Soc. 2004;52(3):428–433.
    1. Rich MW. Epidemiology of atrial fibrillation. J Interv Card Electrophysiol. 2009;25(1):3–8.
    1. Hanon O, Assayag P, Belmin J, et al. Expert consensus of the French Society of Geriatrics and Gerontology and the French Society of Cardiology on the management of atrial fibrillation in elderly people. Arch Cardiovasc Dis. 2013;106(5):303–323.
    1. Anderson JL, Halperin JL, Albert NM, et al. Management of Patients With Atrial Fibrillation (Compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS Recommendations): A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(18):1935–1944.
    1. European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery. Camm AJ, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC) Eur Heart J. 2010;31(19):2369–2429.
    1. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham Study. Arch Intern Med. 1987;147(9):1561–1564.
    1. Hylek EM, D’Antonio J, Evans-Molina C, Shea C, Henault LE, Regan S. Translating the results of randomized trials into clinical practice: the challenge of warfarin candidacy among hospitalized elderly patients with atrial fibrillation. Stroke. 2006;37(4):1075–1080.
    1. Wittkowsky AK. Effective anticoagulation therapy: defining the gap between clinical studies and clinical practice. Am J Manag Care. 2004;10(10 Suppl):S297–S306. discussion S312–S317.
    1. Gladstone DJ, Bui E, Fang J, et al. Potentially preventable strokes in high-risk patients with atrial fibrillation who are not adequately anticoagulated. Stroke. 2009;40(1):235–240.
    1. Pisters R, van Oostenbrugge RJ, Knottnerus IL, et al. The likelihood of decreasing strokes in atrial fibrillation patients by strict application of guidelines. Europace. 2010;12(6):779–784.
    1. Aguilar MI, Hart R. Oral anticoagulants for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks. Cochrane Database Syst Rev. 2005;(3):CD001927.
    1. Marcucci M, Iorio A, Nobili A, et al. Factors affecting adherence to guidelines for antithrombotic therapy in elderly patients with atrial fibrillation admitted to internal medicine wards. Eur J Intern Med. 2010;21(6):516–523.
    1. De Breucker S, Herzog G, Pepersack T. Could geriatric characteristics explain the under-prescription of anticoagulation therapy for older patients admitted with atrial fibrillation? A retrospective observational study. Drugs Aging. 2010;27(10):807–813.
    1. Perera V, Bajorek BV, Matthews S, Hilmer SN. The impact of frailty on the utilisation of antithrombotic therapy in older patients with atrial fibrillation. Age Ageing. 2009;38(2):156–162.
    1. Sanchez-Barba B, Navarrete-Reyes AP, Avila-Funes JA. Are geriatric syndromes associated with reluctance to initiate oral anticoagulation therapy in elderly adults with nonvalvular atrial fibrillation? J Am Geriatr Soc. 2013;61(12):2236–2237.
    1. Zarraga IG, Kron J. Oral anticoagulation in elderly adults with atrial fibrillation: integrating new options with old concepts. J Am Geriatr Soc. 2013;61(1):143–150.
    1. Beyth RJ, Antani MR, Covinsky KE, et al. Why isn’t warfarin prescribed to patients with nonrheumatic atrial fibrillation? J Gen Intern Med. 1996;11(12):721–728.
    1. Monette J, Gurwitz JH, Rochon PA, Avorn J. Physician attitudes concerning warfarin for stroke prevention in atrial fibrillation: results of a survey of long-term care practitioners. J Am Geriatr Soc. 1997;45(9):1060–1065.
    1. Deplanque D, Leys D, Parnetti L, et al. Stroke prevention and atrial fibrillation: reasons leading to an inappropriate management. Main results of the SAFE II study. Br J Clin Pharmacol. 2004;57(6):798–806.
    1. Man-Son-Hing M, Nichol G, Lau A, Laupacis A. Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med. 1999;159(7):677–685.
    1. Anderson N, Fuller R, Dudley N. ‘Rules of thumb’ or reflective practice? Understanding senior physicians’ decision-making about anti-thrombotic usage in atrial fibrillation. QJM. 2007;100(5):263–269.
    1. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285(22):2864–2870.
    1. Gage BF, Yan Y, Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF) Am Heart J. 2006;151(3):713–719.
    1. McCusker J, Bellavance F, Cardin S, Trepanier S, Verdon J, Ardman O. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc. 1999;47(10):1229–12237.
    1. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of Illness in the Aged. The Index of Adl: A Standardized Measure of Biological and Psychosocial Function. JAMA. 1963;185:914–919.
    1. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–198.
    1. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137(2):263–272.
    1. Somme D, Corvol A, Lazarovici C, Lahjibi-Paulet H, Gisselbrecht M, Saint-Jean O. Clinical usefulness in geriatric patients of combining CHADS2 and HEMORR2HAGES scores to guide antithrombotic prophylaxis in atrial fibrillation. Aging Clin Exp Res. 2010;22(4):289–294.
    1. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;138(5):1093–1100.
    1. Levey AS, Coresh J, Greene T, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med. 2006;145(4):247–254.
    1. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139–1151.
    1. Lip GY. Don’t add aspirin for associated stable vascular disease in a patient with atrial fibrillation receiving anticoagulation. BMJ. 2008;336(7644):614–615.
    1. Heidbuchel H, Verhamme P, Alings M, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2013;15(5):625–651.
    1. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146(12):857–867.
    1. van Walraven C, Hart RG, Connolly S, et al. Effect of age on stroke prevention therapy in patients with atrial fibrillation: the atrial fibrillation investigators. Stroke. 2009;40(4):1410–1416.
    1. Mant J, Hobbs FD, Fletcher K, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet. 2007;370(9586):493–503.
    1. Rash A, Downes T, Portner R, Yeo WW, Morgan N, Channer KS. A randomised controlled trial of warfarin versus aspirin for stroke prevention in octogenarians with atrial fibrillation (WASPO) Age Ageing. 2007;36(2):151–156.
    1. Lip GY, Boos CJ. Antithrombotic treatment in atrial fibrillation. Heart. 2006;92(2):155–161.
    1. Donadini MP, Douketis JD. Combined warfarin-aspirin therapy: what is the evidence for benefit and harm and which patients should (and should not) receive it? J Thromb Thrombolysis. 2010;29(2):208–213.
    1. Olesen JB, Lip GY, Hansen ML, et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ. 2011;342:d124.
    1. Reardon G, Nelson WW, Patel AA, Philpot T, Neidecker M. Warfarin for prevention of thrombosis among long-term care residents with atrial fibrillation: evidence of continuing low use despite consideration of stroke and bleeding risk. Drugs Aging. 2013;30(6):417–428.
    1. Friberg L, Rosenqvist M, Lip GY. Net clinical benefit of warfarin in patients with atrial fibrillation: a report from the Swedish atrial fibrillation cohort study. Circulation. 2012;125(19):2298–2307.
    1. Albers GW, Bittar N, Young L, et al. Clinical characteristics and management of acute stroke in patients with atrial fibrillation admitted to US university hospitals. Neurology. 1997;48(6):1598–15604.
    1. Brass LM, Krumholz HM, Scinto JM, Radford M. Warfarin use among patients with atrial fibrillation. Stroke. 1997;28(12):2382–2389.
    1. Gurwitz JH, Monette J, Rochon PA, Eckler MA, Avorn J. Atrial fibrillation and stroke prevention with warfarin in the long-term care setting. Arch Intern Med. 1997;157(9):978–984.
    1. Munschauer FE, Priore RL, Hens M, Castilone A. Thromboembolism prophylaxis in chronic atrial fibrillation. Practice patterns in community and tertiary-care hospitals. Stroke. 1997;28(1):72–76.
    1. Waldo AL, Becker RC, Tapson VF, Colgan KJ. Hospitalized patients with atrial fibrillation and a high risk of stroke are not being provided with adequate anticoagulation. J Am Coll Cardiol. 2005;46(9):1729–1736.
    1. Schulman S, Beyth RJ, Kearon C, Levine MN. Hemorrhagic complications of anticoagulant and thrombolytic treatment: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest. 2008;133(6 Suppl):257S–298S.
    1. Poli D, Antonucci E, Testa S, Tosetto A, Ageno W, Palareti G. Bleeding risk in very old patients on vitamin K antagonist treatment: results of a prospective collaborative study on elderly patients followed by Italian Centres for Anticoagulation. Circulation. 2011;124(7):824–829.
    1. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22(8):983–988.
    1. Gage BF, Boechler M, Doggette AL, et al. Adverse outcomes and predictors of underuse of antithrombotic therapy in medicare beneficiaries with chronic atrial fibrillation. Stroke. 2000;31(4):822–827.
    1. Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study. J Am Coll Cardiol. 2012;60(9):861–867.
    1. Man-Son-Hing M, Laupacis A. Anticoagulant-related bleeding in older persons with atrial fibrillation: physicians’ fears often unfounded. Arch Intern Med. 2003;163(13):1580–1586.
    1. Diug B, Evans S, Lowthian J, et al. The unrecognized psychosocial factors contributing to bleeding risk in warfarin therapy. Stroke. 2011;42(10):2866–2871.
    1. Ogbonna KC, Jeffery SM. Risk versus benefit of non-vitamin K dependent anticoagulants compared to warfarin for the management of atrial fibrillation in the elderly. Drugs Aging. 2013;30(7):513–525.

Source: PubMed

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