Oral anticoagulant nonprescription at discharge in geriatric patients with atrial fibrillation and reduced expected survival.

Abstract

The net clinical benefit of oral anticoagulants (OAC) for atrial fibrillation (AF) in severely frail, older inpatients with limited life expectancy is uncertain. We aimed to assess the prevalence and predictors of OAC nonprescription at discharge and its association with major clinical outcomes at one year. Retrospective cohort study including AF patients aged ≥75 years not on OAC at admission and discharged alive from three Italian acute geriatric wards. Routine Comprehensive Geriatric Assessment (CGA) data at admission and OAC status at discharge were collected. One-year outcomes (all-cause death, stroke/systemic embolism [SSE], and major or clinically relevant non-major bleeding [MB/CRNMB]) were retrieved from administrative databases. Associations were explored using multivariable analyses. Among 2226 patients (median age 87 years, 59.2 % female), 1201 (54.0 %) were discharged without OAC. Nonprescription was associated with severe comorbidity burden and cognitive impairment, complete functional dependence, and history or high risk of bleeding. The same CGA variables were associated with mortality, which occurred in 1139 (51.2 %) patients. OAC nonprescription was independently associated with mortality (aOR 1.93, 95 %CI 1.58-2.36), but not with SSE (aOR 1.1, 95 %CI 0.62-1.93) or MB/CRNMB (aOR 0.94, 95 %CI 0.58-1.53), compared with being alive and event-free at 12 months. A sensitivity analysis on 605 (27.2 %) first-diagnosed AF patients confirmed these findings. In older AF inpatients, OAC nonprescription was associated with CGA variables predictive of reduced survival and independently associated with a higher mortality but not with embolic or bleeding events, suggesting potential futility in this population.