Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
Harvard Medical School, Boston, Massachusetts, USA.
J Am Geriatr Soc. 2023 Sep;71(9):2748-2758. doi: 10.1111/jgs.18375. Epub 2023 Apr 24.
BACKGROUND: Atrial fibrillation is a common cause of stroke among older adults and is often first detected during hospitalization, given frequent use of cardiac telemetry. METHODS: In a 20% national sample of Medicare fee-for-service beneficiaries, we identified patients aged 65-or-older newly diagnosed with atrial fibrillation while hospitalized in 2016. Our primary outcome was an oral anticoagulant claim within 7-days of discharge. Multivariable logistic regression analyses assessed relationships between anticoagulation initiation and thromboembolic and bleeding risk scores while controlling for demographics, frailty, comorbidities, and hospitalization characteristics. RESULTS: Among 38,379 older adults newly diagnosed with atrial fibrillation while hospitalized (mean age 78.2 [SD 8.4]; 51.8% female; 83.3% white), 36,633 (95.4%) had an indication for anticoagulation and 24.6% (9011) of those initiated an oral anticoagulant following discharge. Higher CHA DS -VASc score was associated with a small increase in oral anticoagulant initiation (predicted probability 20.5% [95% CI, 18.7%-22.3%] for scores <2 and 24.9% [CI, 24.4%-25.4%] for ≥4). Elevated HAS-BLED score was associated with a small decrease in probability of anticoagulant initiation (25.4% [CI, 24.4%-26.4%] for score <2 and 23.1% [CI, 22.5%-23.8%] for ≥3). Frailty was associated with decreased likelihood of oral anticoagulant initiation (24.7% [CI, 23.2%-26.2%] for non-frail and 18.1% [CI, 16.6%-19.6%] for moderately-severely frail). Anticoagulant initiation varied by primary reason for hospitalization, with predicted probability highest among patients with a primary diagnosis of atrial fibrillation (46.1% [CI, 45.0%-47.3%]) and lowest among those with non-cardiovascular conditions (13.8% [CI, 13.3%-14.3%]) and bleeds (3.6% [CI, 2.4%-4.8%]). CONCLUSIONS: Oral anticoagulant initiation is uncommon among older adults newly diagnosed with atrial fibrillation during hospitalization, even among patients hospitalized primarily for atrial fibrillation and patients with high thromboembolic risk. Clinicians should discuss risks and benefits of oral anticoagulants with all inpatients found to have atrial fibrillation.
背景：心房颤动是老年人中风的常见原因，由于经常使用心脏遥测，通常在住院期间首次发现。
方法：在 Medicare 按服务收费受益人的 20%全国样本中，我们确定了 2016 年在住院期间新诊断为心房颤动且年龄在 65 岁或以上的患者。我们的主要结局是出院后 7 天内使用口服抗凝剂的情况。多变量逻辑回归分析评估了抗凝药物起始与血栓栓塞和出血风险评分之间的关系，同时控制了人口统计学、脆弱性、合并症和住院特征。
结果：在 38379 名新诊断为住院期间心房颤动的老年人中（平均年龄 78.2[SD 8.4]；51.8%为女性；83.3%为白人），36633 名（95.4%）有抗凝指征，其中 24.6%（9011 名）在出院后开始使用口服抗凝剂。较高的 CHA2DS2-VASc 评分与口服抗凝药物起始率略有增加相关（评分<2 时为 20.5%[95%CI，18.7%-22.3%]，评分≥4 时为 24.9%[CI，24.4%-25.4%]）。升高的 HAS-BLED 评分与抗凝药物起始率略有下降相关（评分<2 时为 25.4%[95%CI，24.4%-26.4%]，评分≥3 时为 23.1%[CI，22.5%-23.8%]）。脆弱性与口服抗凝药物起始率下降相关（非脆弱性患者为 24.7%[95%CI，23.2%-26.2%]，中度至重度脆弱性患者为 18.1%[95%CI，16.6%-19.6%]）。抗凝药物的起始因住院的主要原因而异，主要诊断为心房颤动的患者（46.1%[95%CI，45.0%-47.3%]）和主要诊断为非心血管疾病的患者（13.8%[95%CI，13.3%-14.3%]）以及出血患者（3.6%[95%CI，2.4%-4.8%]）的预测概率最高。
结论：即使是在因心房颤动而住院的患者和血栓栓塞风险较高的患者中，住院期间新诊断为心房颤动的老年人使用口服抗凝剂的情况也并不常见。临床医生应与所有发现患有心房颤动的住院患者讨论口服抗凝剂的风险和获益。
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