Prevalence of Frailty and Associations with Oral Anticoagulant Prescribing in Atrial Fibrillation

Saket R Sanghai¹, Weisong Liu², Weijia Wang³, Subendhu Rongali⁴, Ariela R Orkaby^{5

6}, Jane S Saczynski^{3

7}, Adam J Rose⁸, Alok Kapoor⁹, Wenjun Li⁹, Hong Yu^{9

10

11}, David D McManus^{2

3}

Affiliations

¹ Division of Cardiac Electrophysiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA. sanghaisaket@gmail.com.
² Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
³ Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
⁴ University of Massachusetts, Amherst, MA, USA.
⁵ New England GRECC, VA Boston Health Care System, Boston, MA, USA.
⁶ Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
⁷ Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA.
⁸ Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.
⁹ Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
¹⁰ University of Massachusetts, Lowell, MA, USA.
¹¹ Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA, USA.

PMID: 33948795
PMCID: PMC8904680
DOI: 10.1007/s11606-021-06834-1

Prevalence of Frailty and Associations with Oral Anticoagulant Prescribing in Atrial Fibrillation

Saket R Sanghai et al. J Gen Intern Med. 2022 Mar.

. 2022 Mar;37(4):730-736.

doi: 10.1007/s11606-021-06834-1. Epub 2021 May 4.

Authors

Affiliations

¹ Division of Cardiac Electrophysiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA. sanghaisaket@gmail.com.
² Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.
³ Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
⁴ University of Massachusetts, Amherst, MA, USA.
⁵ New England GRECC, VA Boston Health Care System, Boston, MA, USA.
⁶ Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
⁷ Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA.
⁸ Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.
⁹ Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
¹⁰ University of Massachusetts, Lowell, MA, USA.
¹¹ Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA, USA.

PMID: 33948795
PMCID: PMC8904680
DOI: 10.1007/s11606-021-06834-1

Abstract

Background: Frailty is often cited as a factor influencing oral anticoagulation (OAC) prescription in patients with non-valvular atrial fibrillation (NVAF). We sought to determine the prevalence of frailty and its association with OAC prescription in older veterans with NVAF.

Methods: We used ICD-9 codes in Veterans Affairs (VA) records and Medicare claims data to identify patients with NVAF and CHA₂DS₂VASC ≥2 receiving care between February 2010 and September 2015. We examined rates of OAC prescription, further stratified by direct oral anticoagulant (DOAC) or vitamin K antagonist (VKA). Participants were characterized into 3 categories: non-frail, pre-frail, and frail based on a validated 30-item EHR-derived frailty index. We examined relations between frailty and OAC receipt; and frailty and type of OAC prescribed in regression models adjusted for factors related to OAC prescription.

Results: Of 308,664 veterans with NVAF and a CHA₂DS₂VASC score ≥2, 121,839 (39%) were prescribed OAC (73% VKA). The mean age was 77.7 (9.6) years; CHA₂DS₂VASC and ATRIA scores were 4.6 (1.6) and 5.0 (2.9) respectively. Approximately a third (38%) were frail, another third (32%) were pre-frail, and the remainder were not frail. Veterans prescribed OAC were younger, had higher bleeding risk, and were less likely to be frail than participants not receiving OAC (all p's<0.001). After adjustment for factors associated with OAC use, pre-frail (OR: 0.89, 95% CI: 0.87-0.91) and frail (OR: 0.66, 95% CI: 0.64-0.68) veterans were significantly less likely to be prescribed OAC than non-frail veterans. Of those prescribed OAC, pre-frail (OR:1.27, 95% CI: 1.22-1.31) and frail (OR: 1.75, 95% CI: 1.67-1.83) veterans were significantly more likely than non-frail veterans to be prescribed a DOAC than a VKA.

Conclusions: There are high rates of frailty among older veterans with NVAF. Frailty using an EHR-derived index is associated with decreased OAC prescription.

Keywords: atrial fibrillation; frailty; oral anticoagulation.

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Conflict of interest statement

DDM has received research grant support from Apple Computer, Bristol-Myers Squibb, Boehringer-Ingelheim, Pfizer, Flexcon, Samsung, Philips Healthcare, Biotronik, has received consultancy fees from Bristol-Myers Squibb, Pfizer, Flexcon, Boston Biomedical Associates, Avania. AK has received research grant support from Pfizer and Bristol-Myers Squibb.

Figures

**Figure 1**
a Breakdown of study participants (n=308,664) by frailty categories based on oral anticoagulation prescription status. b Breakdown of study participants (n=121,839) by frailty categories based on the type of oral anticoagulation prescribed. OAC, oral anticoagulation; VKA, vitamin K antagonist; DOAC, direct oral anticoagulant.

See this image and copyright information in PMC

References

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Prevalence of Frailty and Associations with Oral Anticoagulant Prescribing in Atrial Fibrillation

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Prevalence of Frailty and Associations with Oral Anticoagulant Prescribing in Atrial Fibrillation

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