Brunetti Enrico, Presta Roberto, Okoye Chukwuma, Filippini Claudia, Raspo Silvio, Bruno Gerardo, Marabotto Marco, Monzani Fabio, Bo Mario
Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
Geriatrics Unit, Department of Medical Sciences, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy.
J Am Med Dir Assoc. 2024 Mar;25(3):545-551.e4. doi: 10.1016/j.jamda.2024.01.011. Epub 2024 Feb 12.
To investigate prevalence and predictors of oral anticoagulant therapy (OAT) deprescribing in older inpatients with atrial fibrillation (AF), and its association with 1-year incidence of major clinical outcomes.
Multicenter retrospective cohort study.
Inpatients aged ≥75 years with known AF on OAT at admission discharged from 3 Italian acute geriatric wards between January 2014 and July 2018.
Data from a routine Comprehensive Geriatric Assessment (CGA), along with OAT status at discharge were recorded. One-year incidence of all-cause death, stroke or systemic embolism (SSE), and major and clinically relevant nonmajor bleeding (MB/CRNMB) were retrieved from administrative databases. Associations were explored through multilevel analysis.
Among 1578 patients (median age 86 years, 56.3% female), OAT deprescription (341 patients, 21.6%) was associated with bleeding risk, functional dependence and cognitive impairment, and inversely, with previous SSE and chronic AF. Incidences of death, SSE, and MB/CRNMB were 56.6%, 1.5%, and 4.1%, respectively, in OAT-deprescribed patients, and 37.6%, 2.9%, and 4.9%, respectively, in OAT-continued patients, without significant differences between groups. OAT deprescription was associated with all-cause mortality [adjusted odds ratio (aOR) 1.41, 95% CI 1.68-1.85], along with older age, comorbidity burden, cognitive impairment, and functional dependence, but with neither SSE nor MB/CRNMB incidence, as opposed to being alive and free from SSE and MB/CNRMB, respectively (aOR 0.68, 95% CI 0.25-1.82, and aOR 0.95 95% CI 0.49-1.85, respectively). Conversely, OAT deprescription was associated with higher odds of being dead than alive both in patients free from SSE and in those free from MB/CRNMB.
CGA-based OAT deprescribing is common in acute geriatric wards and is not associated with increased SSE. The net clinical benefit of OAT in geriatric patients is strongly related with the competing risk of death, suggesting that functional and cognitive status, as well as residual life expectancy, should be considered in clinical decision making in this population.
调查老年房颤（AF）住院患者口服抗凝治疗（OAT）减药的患病率及预测因素，及其与1年主要临床结局发生率的关联。
多中心回顾性队列研究。
2014年1月至2018年7月期间从3个意大利急性老年病房出院的、入院时已知患有AF且正在接受OAT治疗的≥75岁住院患者。
记录常规综合老年评估（CGA）的数据以及出院时的OAT状态。从行政数据库中检索全因死亡、中风或全身性栓塞（SSE）以及主要和临床相关非大出血（MB/CRNMB）的1年发生率。通过多水平分析探索关联。
在1578例患者（中位年龄86岁，56.3%为女性）中，OAT减药（341例患者，21.6%）与出血风险、功能依赖和认知障碍相关，而与既往SSE和慢性AF呈负相关。OAT减药患者的死亡、SSE和MB/CRNMB发生率分别为56.6%、1.5%和4.1%，继续接受OAT治疗的患者分别为37.6%、2.9%和4.9%，两组之间无显著差异。OAT减药与全因死亡率相关[调整优势比（aOR）1.41，95%置信区间1.68 - 1.85]，还与年龄较大、合并症负担、认知障碍和功能依赖相关，但与SSE和MB/CRNMB发生率均无关，与之相对的分别是存活且无SSE和MB/CNRMB（aOR分别为0.68，95%置信区间0.25 - 1.82，以及aOR 0.95，95%置信区间0.49 - 1.85）。相反，在无SSE的患者和无MB/CRNMB的患者中，OAT减药与死亡几率高于存活几率均相关。
基于CGA的OAT减药在急性老年病房很常见，且与SSE增加无关。OAT在老年患者中的净临床获益与死亡的竞争风险密切相关，这表明在该人群的临床决策中应考虑功能和认知状态以及剩余预期寿命。
