Predictive value of bleeding risk scores in elderly patients with atrial fibrillation and oral anticoagulation

BACKGROUND The predictive value of bleeding risk scores for atrial fibrillation in older patients is not as well known.The goal of this study was to evaluate the predictive value of HASBLED,ORBIT and ATRIA for major bleeding(MB)and intracranial hemorrhage(ICH)in patients≥75 years with atrial fibrillation and oral anticoagulation(OAC).METHODS A retrospective unicenter study including patients≥75 years with atrial fibrillation(AF)and OAC.A total of 7613 patients≥75 years with AF and OAC included between 2014 and 2018(registry:NCT04364516).We analyzed the discriminative value of HASBLED,ATRIA and ORBIT scores for bleeding endpoints(major bleeding as primary endpoint and intracerebral hemorrhage as secondary).Cox regression was used to predict major bleeding with each scale and also for searching other variables potentially predictor of major bleeding.Model discrimination was assessed using Harrell’s C-statistic.Calibration was assessed with goodness-of-fit test proposed by Gronnesby and Borgan.RESULTS During a mean follow up of 4.0 years(IQR:2.4–5.7 years),729 patients developed MB(2.61 per 100 patients/year)and 243 patients developed ICH(0.85 per 100 patients/year).Three scores showed a low discrimination for major bleeding,being ORBIT the best(HASBLED C statistic=0.557;ATRIA C statistic=0.568;ORBIT C statistic=0.595)and also a low discrimination for ICH(HASBLED C statistic=0.509;ATRIA C statistic=0.522;ORBIT C statistic=0.526).Among the variables that are part of the scores and other baseline characteristics,after multivariable adjustment only sex(male),dementia,prior admission for bleeding,anemia and liver disease were found as a predictors of MB.CONCLUSIONS In older patients under oral anticoagulation with atrial fibrillation,the risk scores HASBLED,ATRIA and ORBIT showed a weak discrimination for major bleeding and intracranial hemorrhage.Therefore,other better alternatives should be evaluated for this purpose.

Safety of digoxin in nonagenarian patients with atrial fibrillation:lessons from the Spanish Multicenter Registry

BACKGROUND The association between digoxin and mortality is an unclear issue.In older patients with atrial fibrillation(AF),where use of digoxin is frequent,the evidence of its safety is scarce.Our aim is to assess the safety of digoxin in nonagenarian patients with AF.METHODS We evaluated data from 795 nonagenarian patients with non-valvular AF from the Spanish Multicenter Registry.We analyzed the relationship between digoxin and all-cause mortality with the Cox proportional-hazards model.RESULTS Follow-up was 27.7±18.3 months.Mean age was 92.5±3.8 years,and 71%of nonagenarian patients were female.Digoxin was not associated with increased risk of mortality[adjusted hazard ratio(aHR)=1.16,95%CI:0.96−1.41,P=0.130].However,we found a significant increase in mortality in the subgroup with estimated glomerular filtration rate(eGFR)<30 mL/min per 1.73 m^(2)(aHR=2.01,95%CI:1.13−3.57,P=0.018),but not in the other subgroups of eGFR(30−59 mL/min per 1.73 m^(2) and≥60 mL/min per 1.73 m^(2)).When exploring the risk of mortality according to sex,male subgroup was associated with an in-crease in mortality(aHR=1.48,95%CI:1.02−2.14,P=0.041).This was not observed in females subgroup(aHR=1.03,95%CI:0.81−1.29,P=0.829).Based on the presence or absence of heart failure,we did not find significant differences(aHR=1.20,95%CI:0.87−1.65,P=0.268 vs.aHR=1.15,95%CI:0.90−1.47,P=0.273,respectively).CONCLUSIONS In our large registry of nonagenarian patients with AF,we did not find an association between digoxin and mortality in the total sample.However,in the subgroup analyses,we found an increase in mortality with the use of digoxin in men and in patients with an eGFR<30 mL/min per 1.73 m^(2).