Frailty and oral anticoagulant prescription in adults with atrial fibrillation: A systematic review

ObjectivesThe objectives of this study were to determine the prevalence of frailty in the context of atrial fibrillation (AF); to identify the most commonly used frailty instruments in AF; and to describe the effect of frailty on non-vitamin K oral anticoagulant (NOAC) prescription for stroke prevention in adults with AF.MethodsA systematic search of databases, including Medline, Embase, Web of Science, Cochrane Library, Scopus, and CINAHL, was conducted using search terms including "atrial fibrillation," "frailty," and "anticoagulation." A narrative synthesis was undertaken.ResultsA total of 92 articles were screened, and 12 articles were included. The mean age of the participants (n = 212,111) was 82 years (range = 77-85 years) with 56% of participants identified as frail and 44% identified non-frail. A total of five different frailty instruments were identified: the Frailty Phenotype (FP; n = 5, 42%), the Clinical Frailty Scale (CFS; n = 4, 33%), Cumulative Deficit Model of Frailty (CDM; n = 1, 8%), Edmonton Frail Scale (n = 1, 8%) and the Resident Assessment Instrument - Minimum Data Set (RAI-MDS 2.0; n = 1, 8%). Frailty was identified as an important barrier to anticoagulant therapy with 52% of the frail population anticoagulated vs 67% non-frail.ConclusionFrailty is an important consideration in anticoagulation decision making for stroke prevention in patients with AF. There is scope to improve frailty screening and treatment. Frailty status is an important risk marker and should be considered when evaluating stroke risk alongside congestive heart failure, hypertension, age >= 75 years, diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism, vascular disease, age 65-74 years, sex category (CHA(2)DS(2)-VASc) and Hypertension, Abnormal renal/liver function, Stroke, Bleeding, Labile, Elderly, and Drugs (HAS-BLED) scores. Frailty is an important consideration in anticoagulation decision making for stroke prevention in patients with AF. There is scope to improve frailty screening and treatment in patients with AF. Frailty status is an important risk marker that should be considered when evaluating stroke risk alongside tools such as the CHA2DS2VASc and HAS-BLED.image