Recurrence or persistence of atrial fibrillation is associated with frailty and adverse outcomes: the SAGE-AF cohort study

Atrial fibrillation (AF) is a prevalent arrhythmia in older adults. While traditional risk factors are well-established, the role of frailty, a marker of biological aging, in the course of AF over time remains underexplored.

We utilized data from 854 older adults (≥ 65 years) with AF and a CHA₂DS₂-VASc score ≥ 2, enrolled in the Systematic Assessment of Geriatric Elements (SAGE-AF) prospective cohort study, who had electrocardiograms (ECGs) available at both a baseline and two-year follow-up visit. Participants were classified as having AF recurrence if baseline ECG showed sinus rhythm and year-two ECG showed AF, and as having AF persistence if AF was present at both time points.

We included 773 older adults in our analysis (mean age 76 ± 7, 52% male, 92% white). AF recurrence or persistence was detected on ECG in 379 (49%) of participants at two-year follow-up. Baseline frailty or pre-frailty was significantly associated with higher odds of AF recurrence or persistence (aOR 1.52, 95%CI 1.03–2.25). Participants with recurrent or persistent AF had a higher incidence of major bleeding events, even after adjustment for anticoagulation, age, and other cardiovascular risk factors (aHR 1.87, 95%CI 1.01–3.45).

Frailty or pre-frailty increases odds of AF recurrence or persistence at two years, underscoring the potential role of biological aging in influencing the course of AF over time. AF recurrence or persistence was associated with greater hazards of major bleeding, even after adjustment for key clinical factors, suggesting residual risk not captured by measured covariates.