Frailty and cognitive impairment are not reasons to withhold anticoagulation in people with atrial fibrillation but screening could guide management

This editorial comments on the article by Mailhot et al. (Mailhot, McManus, Waring, Lessard, Goldberg, Bamgbade, Saczynski (2020), 'Frailty, cognitive impairment, and anticoagulation among older adults with nonvalvular atrial fibrillation', Journal of the American Geriatrics Society, 68 (12) 2778-2786, https://doi.org/10.1111/jgs.16756). Oral anticoagulants (OACs) reduce the risk of stroke for people with atrial fibrillation (AF), and OACs are recommended in evidence-based guidelines for most people with AF.1 The net clinical benefit of OACs compared with no treatment or aspirin is clear for most people with AF, apart from those at lowest stroke risk.2 The common risk factors for incident AF are also risk factors for stroke and bleeding in AF.3. There are well-validated risk scores to assess stroke and bleeding risks in AF, and an independent Patient-Centered Outcomes Research Institute (PCORI) systematic review and evidence appraisal found that of commonly used AF risk scores, the CHADS2, CHA2DS2−VASc and HAS-BLED scores were the best validated scores for use in clinical practice.4 However, stroke risk in people with AF is increased by aging and incident risk factors, so should be regularly repeated, given that risk is dynamic and not a static “one-off” assessment.5 Similarly, bleeding risk is dynamic and should be determined for all people with AF before (and after) commencing OAC treatment.6 Indeed, regular reassessment using the HAS-BLED score is associated with mitigation of modifiable bleeding risk factors, reduced bleeding risk, and an increase in OAC use.7 Importantly, a high bleeding risk score should not be used as the sole reason to not initiate anticoagulation. Instead, people should be appropriately treated with OAC, monitored and also reassessed to determine any changes in risks over time. There is no exception in current guidelines for initiating anticoagulation for AF in people with frailty or cognitive impairment.