Frailty, Anticoagulation Use and Clinical Outcomes in Older Adults With Atrial Fibrillation: A Prospective Observational Study

INTRODUCTION
Frailty is common among older adults with atrial fibrillation (AF) and may influence anticoagulation prescribing despite not being incorporated into conventional stroke and bleeding risk assessment tools. Concerns regarding falls, bleeding risk and multimorbidity may contribute to therapeutic uncertainty. This study evaluated the association between frailty, anticoagulation use and clinical outcomes in older adults admitted with AF.

METHODS
A prospective observational study was conducted across four elderly care wards in a UK district general hospital. Consecutive inpatients aged ≥75 years with AF were recruited over 12 months. Frailty was assessed using the Rockwood Clinical Frailty Scale (RCFS). Baseline demographics, anticoagulation status, CHA₂DS₂-VASc and HAS-BLED scores were recorded. Patients were followed for six months after discharge. Outcomes included stroke, major bleeding, mortality, and hospital readmission. Multivariable logistic regression was performed to identify predictors of mortality.

RESULTS
A total of 171 patients were included, of whom 152 (88.9%) were classified as frail and 19 (11.1%) as non-frail. Anticoagulation was prescribed in 156 patients (91.2%), predominantly with direct oral anticoagulants. AF was more common among frail patients than non-frail patients (76.8% versus 31.3%). During follow-up, four major bleeding events (2.6%) occurred among anticoagulated patients, including one haemorrhagic stroke. One ischaemic stroke occurred in a patient who was not anticoagulated. Frailty independently predicted mortality (OR=1.34, 95% CI 1.12–1.59; p=0.001), whereas anticoagulation status showed a statistically insignificant relationship with mortality (OR 0.72, 95% CI 0.28–1.86; p=0.49).

CONCLUSIONS
Frailty was associated with a greater burden of AF and independently predicted mortality. Anticoagulation use was high, and major bleeding events were uncommon during follow-up. However, these findings should be interpreted cautiously given the single-centre design, relatively small sample size and marked imbalance between frail and non-frail groups. Larger multicentre studies are required to better define the role of frailty in anticoagulation decision-making for older adults with AF.