One-Year Mortality in Hospitalized, Frail Older Adults with Atrial Fibrillation on Oral Anticoagulant Therapy: Impact of Stroke and Bleeding Events.

Abstract

Background: Atrial fibrillation (AF) is common in older adults, and anticoagulation is recommended for those aged 75 years and older. Still, many individuals remain untreated due to concerns about the benefit-risk balance, particularly among the frail. This study examines the association of incident ischemic stroke (IS) and major or clinically relevant nonmajor bleeding (MB/CRNMB) on 1-year mortality in older patients receiving oral anticoagulants (OAC).

Methods: This retrospective multicenter study included individuals aged ≥ 75 years with AF, discharged between 2014 and 2018 from three acute geriatric units. Baseline functional and frailty status were collected. OAC use at discharge was identified through review of clinical charts. Data on 1-year survival, IS, and MB/CRNMB were extracted from a centralized database. Associations with 1-year mortality were analyzed using a multivariable Cox model with IS and MB/CRNMB as time-dependent variables.

Results: The study included 1684 patients with AF, median age 86 years (interquartile range 82-90), of whom 59.8% were female. Most patients were frail (67.2%) or prefrail (24.2%). Within 1 year, 609 (36.2%) patients died; there were 50 (2.9%) cases of IS and 79 (4.7%) cases of MB/CRNMB. Multivariable Cox analysis showed that incident MB/CRNMB (hazard ratio, HR: 3.82, 95% confidence intervals, CI 2.68-5.45) and IS (HR: 1.82, 95% CI 1.14-2.90) were independently associated with increased 1-year mortality.

Conclusions: In total, one third of older adults with AF receiving OAC die within a year of discharge. Incident MB/CRNMB was more strongly associated with reduced survival than incident IS, underscoring the clinical complexity of anticoagulation management in this high-risk population.