Impact of Clinical Frailty Scale on Clinical Outcomes and Decision-Making to Prescribe Anticoagulation Following LAAC

Abstract Background Anticoagulants are often less frequently prescribed in elderly patients with atrial fibrillation (AF) because of concerns regarding high bleeding risk, despite their increased susceptibility to embolic stroke and systemic embolization. This study evaluated the impact of the Clinical Frailty Scale (CFS) on clinical outcomes and decision-making for prescribing antithrombotic therapy following left atrial appendage closure (LAAC) in a large contemporary registry. Methods The OCEAN-LAAC registry included 1,409 patients who underwent LAAC. Outcomes and antithrombotic prescriptions after the procedure were compared between groups stratified by CFS into 1–3 and 4–8. Results Patients with CFS 4–8 were more likely to have a history of stroke and demonstrated lower serum albumin and hemoglobin levels, consistent with advanced frailty. In multivariate analysis, CFS 4–8 was independently associated with higher all-cause mortality at one year compared with CFS 1–3 (adjusted hazard ratio 1.89; 95% confidence interval 1.05–3.41). By one year, patients with CFS 4–8 more frequently discontinued antithrombotic therapy, without significant differences in ischemic stroke or device-related thrombotic events. Notably, major bleeding was more common in the CFS 4–8 group, reflecting their advanced clinical vulnerability. Conclusion Greater frailty, as assessed by CFS, was independently associated with increased all-cause mortality following LAAC. Although frailty influenced patterns of antithrombotic therapy in this real-world registry, thrombotic events remained comparable between CFS groups, supporting the feasibility of individualized, frailty-guided post-LAAC management. These findings underscore the importance of incorporating frailty assessment into multidisciplinary Brain–Heart team decision-making.