Management of atrial fibrillation for older people with frailty: a systematic review and meta-analysis

BACKGROUND: despite a large and growing population of older people with frailty and atrial fibrillation (AF), there is a lack of guidance on optimal AF management in this high-risk group. OBJECTIVE: to synthesise the existing evidence base on the association between frailty, AF and clinical outcomes. METHODS: a systematic review of studies examining the association between validated measures of frailty, AF and clinical outcomes, and meta-analysis of the association between frailty and oral anticoagulation (OAC) prescription. RESULTS: twenty studies (30,883 patients) were included, all observational. Fifteen were in hospital, four in the community, one in nursing care. Risk of bias was low-to-moderate. AF prevalence was 3%-38%. In people with AF, frailty was associated with increased stroke incidence, all-cause mortality, symptom severity and length of hospital stay.Meta-analysis of six studies showed frailty was associated with decreased OAC prescription at hospital admission (pooled adjusted OR 0.45 [95%CI 0.22-0.93], three studies), but not at discharge (pooled adjusted OR 0.40 [95%CI 0.13-1.23], three studies). A community-based study showed increased OAC prescription associated with frailty (OR 2.33 [95%CI 1.03-5.23]). CONCLUSION: frailty is common, and associated with adverse clinical outcomes in patients with AF. There is evidence of an association between frailty status and OAC prescription, with different direction of effect in community compared with hospital cohorts. Despite the majority of care for older people being provided in the community, there is a lack of evidence on the association between frailty, AF, anticoagulation and clinical outcomes to guide optimal care in this setting.