Multi-morbidity, frailty and self-care: Important considerations in treatment with anticoagulation drugs. Outcomes of the AFASTER study

Background: Chronic heart failure (CHF) and atrial fibrillation (AF) are complex cardiogeriatric syndromes mediated by physical, psychological and social factors. Thromboprophylaxis is an important part of avoiding adverse events in these syndromes, particularly stroke. Purpose: This study sought to describe the clinical characteristics of a cohort of patients admitted to hospital with CHF and concomitant AF and to document the rate and type of thromboprophylaxis. We examined the practice patterns of the prescription of treatment and determined the predictors of adverse events. Methods: Prospective consecutive participants with CHF and concomitant AF were enrolled during the period April to October 2013. Outcomes were assessed at 12 months, including all-cause readmission to hospital and mortality, stroke or transient ischaemic attack, and bleeding. Results: All-cause readmission to hospital was frequent (68%) and the 12-month all-cause mortality was high (29%). The prescription of anticoagulant drugs at discharge was statistically significantly associated with a lower mortality at 12 months (23 vs. 40%; p=0.037; hazards ratio 0.506; 95% confidence interval 0.267-0.956), but was not associated with lower rates of readmission to hospital among patients with CHF and AF. Sixty-six per cent of participants were prescribed anticoagulant drugs on discharge from hospital. Self-reported self-care behaviour and 'not for cardiopulmonary resuscitation' were associated with not receiving anticoagulant drugs at discharge. Although statistical significance was not achieved, those patients who were assessed as frail or having greater comorbidity were less likely to receive anticoagulant drugs at discharge. Conclusion: This study highlights multi-morbidity, frailty and self-care to be important considerations in thromboprophylaxis. Shared decision-making with patients and caregivers offers the potential to improve treatment knowledge, adherence and outcomes in this group of patients with complex care needs.