Patients with Cognitive Impairment Less Likely to Get OACs

Patients who have atrial fibrillation and cognitive impairment and frailty were less likely to receive oral anticoagulants (OACs), a recent study shows.

In the study, published in the February 2019 American Heart Journal, Malini Madhaven, MD, a cardiologist and internist at the Mayo Clinic in Rochester, MN, and her colleagues set out to determine how cognitive impairment and frailty may impact both therapy and outcomes in atrial fibrillation (AF).

The researchers examined the prevalence of clinically-recognized cognitive impairment and frailty (as defined by the criteria of the American Geriatric Society) in the Outcomes Registry for Better Informed Care in AF (ORBIT AF) and associated adjusted outcomes via multivariable Cox regression. Notably, there were a significant portion of patients who were over 75 years old.

Among 9,749 patients with AF, the researchers identified cognitive impairment in 3% of patients and frailty in 5.9% of patients. Sixty-eight percent of frail patients received an OAC compared to 77% of those who were not frail. Seventy percent of patients with cognitive impairment received an OAC compared to 77% of patients without cognitive impairment.

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Both cognitive impairment and frailty were associated with increased risk of death, but were not associated with stroke/transient ischemic attack (TIA) or major bleeding.

“Those with cognitive impairment or frailty in AF had higher predicted risk for stroke and higher observed mortality, yet were less likely to be treated with OAC. Despite this, the benefits of OAC were similar in patients with and without cognitive impairment or frailty,” Madhavan writes.

Similarly, previous studies found lower rates of prescribing OACs in patients with AF who have dementia, Cardiac Rhythm Newsreports. “However, the use of oral anticoagulation has been shown by Jacobs et al. to reduce the incidence of cognitive impairment in patients with atrial fibrillation.”

Another study found a high rate of doctors stopping warfarin in patients with AF who were perceived as being frail or having low life expectancy, despite high rates of mortality, bleeding, and stroke after discontinuing warfarin, the article says.

Frailty should not be a contraindication to oral anticoagulation prescription in patients with AF, Madhavan writes. In addition, “atrial fibrillation patients with cognitive impairment should be considered for oral anticoagulation based on their clinical factors,” she writes.

Future studies should consider whether routine assessment of frailty indices should be used to guide AF therapy, according to Madhaven.