Management of Atrial Fibrillation in Older Patients by Morbidity Burden: Insights From Get With The Guidelines-Atrial Fibrillation

Abstract

Background Knowledge is scarce regarding how multimorbidity is associated with therapeutic decisions regarding oral anticoagulants (OACs) in patients with atrial fibrillation. Methods and Results We conducted a cross-sectional study of hospitalized patients with atrial fibrillation using the Get With The Guidelines-Atrial Fibrillation registry from 2013 to 2019. We identified patients ≥65 years and eligible for OAC therapy. Using 16 available comorbidity categories, patients were stratified by morbidity burden. A multivariable logistic regression model was used to determine the odds of receiving OAC prescription at discharge by morbidity burden. We included 34 174 patients with a median (interquartile range) age of 76 (71-83) years, 56.6% women, and 41.9% were not anticoagulated at admission. Of these patients, 38.6% had 0 to 2 comorbidities, 50.7% had 3 to 5 comorbidities, and 10.7% had ≥6 comorbidities. The overall discharge OAC prescription was high (85.6%). The prevalence of patients with multimorbidity increased from 59.7% in 2014 to 64.3% in 2019 (P trend=0.002). Using 0 to 2 comorbidities as the reference, the adjusted odds ratio (95% CI) of OAC prescription were 0.93 (0.82, 1.05) for patients with 3 to 5 comorbidities and 0.72 (0.60, 0.86) for patients with ≥6 comorbidities. In those with ≥6 comorbidities, the most common reason for nonprescription of OACs were frequent falls/frailty (31.0%). Conclusions In a contemporary quality-of-care database of hospitalized patients with atrial fibrillation eligible for OAC therapy, multimorbidity was common. A higher morbidity burden was associated with a lower odds of OAC prescription. This highlights the need for interventions to improve adherence to guideline-recommended anticoagulation in multimorbid patients with atrial fibrillation.

Keywords: anticoagulation; atrial fibrillation; comorbidities; multimorbidity; oral anticoagulants; prescription; quality of care.

Figure 1. Flowchart of the study inclusion.

*Strict contraindications for OAC therapy were prior bleeding events, prior intracranial hemorrhage, allergy, recent operation, or severe comorbid illness (eg, severe renal or liver disease). AC indicates anticoagulation; AF, atrial fibrillation; and OAC, oral anticoagulant.

Figure 2. Distribution of comorbidity scores.

Histogram of the comorbidity score distribution with mean, SD, median, lower (25%) quartile, upper (75%) quartile, minimum and maximum.

Figure 3. Prevalence of multimorbidity burden of ≥3 and ≥6 (y‐axis) by calendar year (x‐axis).

Prevalence of multimorbidity by calendar year is shown for all patients with ≥3 comorbidities and ≥6 comorbidities, including 95% CI and P test for trend.