O'Caoimh R, Igras E, Ramesh A, Power B, O'Connor K, Liston R
Dr Rónán O'Caoimh, Centre for Gerontology and Rehabilitation, University College Cork, St Finbarrs Hospital, Douglas road, Cork City, Ireland, Email:
J Frailty Aging. 2017;6(1):46-52. doi: 10.14283/jfa.2016.118.
Atrial fibrillation (AF) is common among frail older adults. Oral anticoagulation (OAC) is particularly challenging for these due to overlapping stroke and bleeding risk factor profiles.
To compare the utility of stroke and haemorrhage risk-prediction instruments in the treatment of AF among frail older adults.
Cross-sectional study.
Frail residents in four nursing homes with a Clinical Frailty Scale score ≥5 (median 7±0).
The prevalence of AF was assessed by ECG and chart review. Stroke (CHADS2 and CHA2DS2-VASc) and bleeding (HASBLED and HEMORR2HAGES) risk-prediction scores were then applied. A validated, risk-based, colour-coded decision support tool, incorporating these instruments, was then used to create a risk matrix and assess the appropriateness of OAC.
In total, 225 patients were included. The distribution of CFS scores was similar irrespective of AF status. In all, 86/225 (38%) had any history of AF. Of these, only 15/86 (17%) were prescribed OAC. All those in AF scored ≥2 on the CHA2DS2-VASc. One-third also scored high-risk of bleeding using HAS-BLED or HEMORR2HAGES. Risk-prediction scores were similar between those with 'known' (documented) and occult (only on ECG) AF. The colour-coded decision tree suggested that OAC would be recommended for the majority in AF when HAS-BLED (60/86, 70%) was used as the bleeding risk-prediction instrument. Despite this, only 12/60 (20%) were anticoagulated. When HEMORR2HAGES was incorporated instead, one patient was advised OAC, the remainder no treatment (57%) or an antiplatelet (42%).
Stroke risk was high and bleeding risk levels comparatively low, suggesting that the balance of risk may favor OAC for AF in this cohort of patients with advanced frailty. Despite this and the high prevalence of AF, OAC prescription rates were low. The decision-support tool used showed mixed results, depending on the bleeding-risk score incorporated, suggesting that while useful, they should not replace clinical judgement.
心房颤动（AF）在体弱的老年人中很常见。由于中风和出血风险因素相互重叠，口服抗凝治疗（OAC）对这些患者尤其具有挑战性。
比较中风和出血风险预测工具在体弱老年人房颤治疗中的效用。
横断面研究。
四家养老院中临床衰弱量表评分≥5（中位数7±0）的体弱居民。
通过心电图和病历审查评估房颤的患病率。然后应用中风（CHADS2和CHA2DS2-VASc）和出血（HASBLED和HEMORR2HAGES）风险预测评分。然后使用一个经过验证的、基于风险的、彩色编码的决策支持工具，结合这些工具，创建一个风险矩阵并评估OAC的适用性。
总共纳入了225名患者。无论房颤状态如何，CFS评分的分布相似。总共有86/225（38%）有房颤病史。其中，只有15/86（17%）接受了OAC治疗。所有房颤患者的CHA2DS2-VASc评分均≥2。三分之一的患者使用HAS-BLED或HEMORR2HAGES评分也为高出血风险。“已知”（有记录）房颤和隐匿性（仅心电图显示）房颤患者的风险预测评分相似。彩色编码决策树表明，当使用HAS-BLED作为出血风险预测工具时，大多数房颤患者会被推荐使用OAC。尽管如此，只有12/60（20%）接受了抗凝治疗。当改用HEMORR2HAGES时，一名患者被建议使用OAC，其余患者不治疗（57%）或使用抗血小板药物（42%）。
中风风险高而出血风险水平相对较低，这表明在这个体弱程度较高的患者队列中，风险平衡可能有利于房颤患者使用OAC。尽管如此，且房颤患病率高，但OAC处方率较低。所使用的决策支持工具显示出不同的结果，这取决于所纳入的出血风险评分，这表明虽然有用，但它们不应取代临床判断。
