Geriatric Conditions and Prescription of Vitamin K Antagonists vs. Direct Oral Anticoagulants Among Older Patients With Atrial Fibrillation: SAGE-AF

David D McManus; Catarina Kiefe; Darleen Lessard; Molly E Waring; David Parish; Hamza H Awad; Francesca Marino; Robert Helm; Felix Sogade; Robert Goldberg; Robert Hayward; Jerry Gurwitz; Weijia Wang; Tanya Mailhot; Bruce Barton; Jane Saczynski

doi:10.3389/fcvm.2019.00155

Geriatric Conditions and Prescription of Vitamin K Antagonists vs. Direct Oral Anticoagulants Among Older Patients With Atrial Fibrillation: SAGE-AF

Front Cardiovasc Med. 2019 Oct 30:6:155. doi: 10.3389/fcvm.2019.00155. eCollection 2019.

Authors

David D McManus^{1

2}, Catarina Kiefe¹, Darleen Lessard^{1

2}, Molly E Waring³, David Parish⁴, Hamza H Awad⁴, Francesca Marino², Robert Helm⁵, Felix Sogade⁶, Robert Goldberg¹, Robert Hayward⁷, Jerry Gurwitz⁸, Weijia Wang², Tanya Mailhot^{9

10}, Bruce Barton¹, Jane Saczynski⁹

Affiliations

¹ Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.
² Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States.
³ Department of Allied Health Sciences, University of Connecticut, Mansfield, MA, United States.
⁴ Department of Community Medicine/Internal Medicine, Mercer University School of Medicine, Macon, GA, United States.
⁵ Department of Medicine, Boston University School of Medicine, Boston, MA, United States.
⁶ Department of Medicine, Mercer University School of Medicine, Macon, GA, United States.
⁷ Department of Electrophysiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, United States.
⁸ Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA, United States.
⁹ Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, United States.
¹⁰ Montreal Heart Institute Research Center, Montreal, QC, Canada.

Abstract

Background: Geriatric conditions are common among patients with atrial fibrillation (AF) and relate to complications of oral anticoagulation (OAC). Objective: To examine the prevalence of geriatric conditions among older patients with AF on OAC and relate type of OAC to geriatric conditions. Methods: Participants had a diagnosis of AF, were aged ≥65 years, CHA₂DS₂VASC ≥ 2, and had no OAC contraindications. Participants completed a 6-component geriatric assessment that included validated measures of frailty (CHS Frailty Scale), cognitive function (MoCA), social support (MOS), depressive symptoms (PHQ9), vision, and hearing. Type of OAC prescribed was documented in medical records. Results: 86% of participants were prescribed an OAC. These participants were on average aged 75.7 (SD: 7.1) years, 49% were women, two thirds were frail or pre-frail, and 44% received a DOAC. DOAC users were younger, had lower CHA₂DS₂VASC and HAS-BLED scores, and were less likely to be frail. In Massachusetts, pre-frailty was associated with a significantly lower odds of DOAC vs. VKA use (OR = 0.64, 95%CI 0.45, 0.91). Pre-frailty (OR = 0.33, 95%CI 0.18-0.59) and social isolation (OR = 0.38, 95%CI 0.14-0.99) were associated with lower odds of DOAC receipt in patients aged 75 years or older. Social isolation was associated with higher odds of DOAC use (OR = 2.13, 95%CI 1.05-4.29) in patients aged 65-74 years. Conclusions: Geriatric conditions were common and related to type of OAC prescribed, differentially by age group. Research is needed to evaluate whether a geriatric examination can be used clinically to better inform OAC decision-making in older patients with AF.

Keywords: anticoagulation; atrial fibrillation; frailty; older adults; social isolation.