Acute coronary syndrome (ACS) is a critical manifestation of cardiovascular disease, which necessitates rigorous secondary prevention to reduce recurrent events and mortality. While lipid-lowering therapy (LLT) is integral to post-ACS secondary prevention, long-term adherence remains a significant clinical challenge. This study evaluated psychological, socioeconomic, and clinical factors associated with LLT adherence in patients after ACS, with a specific focus on mental health components and chronic comorbidities. ACS survivors were included from the Transitions, Risks, and Actions in Coronary Events-Center for Outcomes Research and Education cohort (TRACE-CORE). Baseline demographic, medical history and mental health data - including the 36-Item Short Form Survey (SF-36) Mental Component (MCS) and Physical Component Scores (PCS) and the Patient Health Questionnaire-9 (PHQ-9)- were collected during hospitalization. Adherence to LLT was assessed up to twelve-months post-discharge. We performed a comparative analysis between patients with complete versus incomplete follow-up and utilized binary logistic regression to identify factors associated with adherence to LLT. Of the cohort, 51

Objective: Smartwatches with photoplethysmographic (PPG) sensors are ideal for early atrial fibrillation (AF) detection through continuous monitoring. However, prior deep learning was limited either to controlled environments, to minimize motion artifacts, or to short duration data collection. Additionally, premature atrial/ventricular contractions (PAC/PVC), which often confound AF detection algorithms, remains understudied due to limited datasets. Current state-of-the-art methods achieve only 75% sensitivity for PAC/PVC class on minimally motion artifact corrupted PPG data, despite showing 97% AF detection accuracy. Methods: We addressed the above limitations using data from the recently completed NIH-funded Pulsewatch clinical trial which collected over two weeks of smartwatch PPG data from 106 subjects. Our computationally efficient 1D bi-directional Gated Recurrent Unit deep learning model incorporated multi-modal inputs (1D PPG, accelerometer, and heart rate data) to classify normal sinus rhythm, AF, and PAC/PVC. Results: Our model achieved an unprecedented 83% sensitivity for PAC/PVC detection while maintaining a high accuracy of 97.31% for AF detection, outperforming the best retrained state-of-the-art model by 20.81% and 2.55%, respectively. It was also 14 times more computationally efficient and 2.7 times faster. Testing on two external PPG datasets collected with a different smartwatch and a fingertip PPG sensor, our model demonstrated better generalizability with macro-averaged AUROC values of 96.22% and 94.17%, respectively. Conclusion: A light-weight multimodal input deep learning model can accurately distinguish PAC/PVC from AF, reducing false positive detection of AF. Significance: Accurate AF and PAC/PVC detection with minimal false positive detection can enhance clinical and public acceptance of smartwatch-based AF monitoring.

Abstract Background 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. Methods We utilized data from 854 older adults (≥ 65 years) with AF and a CHA 2 DS 2 -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. Results 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). Conclusion 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.

Atrial fibrillation (AF) is a common condition in older adults, often associated with increased risks of cognitive decline and frailty. White matter hyperintensities (WMH), visible on neuroimaging and quantified by the Fazekas score, have been linked to both cognitive and physical impairments. However, the relationship between WMH, cognitive decline, and frailty in older adults with AF remains relatively underexplored. This study analyzed data from 86 participants in the SAGE-AF cohort, a two—year prospective multicenter cohort study of older adults with AF, who also had neuroimaging performed for clinical indications. WMH severity was assessed by independent reviewers using Fazekas scores from brain imaging. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA), and frailty was assessed at baseline as well as 1- and 2-year follow-up visits by trained examiners as part of the SAGE-AF study protocol. Participants were characterized based on the severity of their white matter hyperintensities and compared to baseline and two-year cognitive and physical functional status. Longitudinal regression models were used to adjust for demographic, clinical, and geriatric covariates. Participants with higher Fazekas scores (grades 2–3) demonstrated significantly lower baseline and follow-up MoCA scores and were more likely to meet frailty criteria over a two-year follow-up period. After adjusting for multiple factors known to influence cognitive decline, greater white matter hyperintensity (Fazekas grades 2–3) remained associated with a 2.6-fold increased risk of cognitive impairment at (p = 0.04) and a 2.7-fold increased risk of frailty at (p = 0.02). Higher Fazekas scores are related to cognitive decline and frailty in older adults with AF, emphasizing WMH as a critical biomarker for aging-related impairments. Neuroimaging tools like Fazekas scoring could enhance risk stratification and inform targeted interventions for this vulnerable population.

BackgroundAtrial fibrillation (AF) is the most common sustained arrhythmia and is linked to increased risk of stroke, heart failure, and mortality. Circulating extracellular RNAs (exRNAs), which regulate gene expression and reflect underlying biological processes, are potential biomarkers for atrial fibrillation.MethodsAs part of an ongoing, larger study into extracellular RNAs (exRNAs) as potential biomarkers for cardiovascular disease, we analyzed exRNA profiles in a subset of 296 survivors of acute coronary syndrome (ACS) enrolled in the Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) cohort. A total of 318 exRNAs were quantified, selected a priori based on prior findings from the Framingham Heart Study. We assessed associations between circulating exRNAs and echocardiographic intermediate phenotypes relevant to atrial fibrillation (AF), including left atrial dimension, left ventricular (LV) mass, LV end-diastolic volume, and global longitudinal strain. Subsequently, we used logistic regression models to evaluate whether the exRNAs associated with these phenotypes were also associated with a history of AF (n = 18, 5.4%). Downstream bioinformatics analyses were performed to identify putative target genes, enriched gene ontology categories, and molecular pathways regulated by these candidate microRNAs.ResultsWe identified 77 extracellular RNAs (exRNAs) that were significantly associated with increased left ventricular (LV) mass and at least one additional echocardiographic intermediate phenotype. Among these, miR-17-5p and miR-574-3p were also significantly associated with a history of atrial fibrillation (AF), with odds ratios of 1.58 (95% CI: 1.10–2.26) and 2.16 (95% CI: 1.03–4.54), respectively. Predicted gene targets of these miRNAs were enriched in pathways implicated in atrial remodeling and arrhythmogenesis. Key overlapping canonical pathways included the Senescence Pathway, Idiopathic Pulmonary Fibrosis Signaling, ERK5 Signaling, RHO GTPase Cycle, and HGF Signaling.ConclusionsCirculating exRNAs, including miR-17-5p and miR-574-3p, are associated with cardiac remodeling and a history of AF in ACS survivors. These findings highlight their potential as biomarkers of atrial remodeling and implicate key molecular pathways involved in AF pathogenesis.

OBJECTIVE:Given the elevated mortality in individuals with acute coronary syndrome and increased adiposity, delineating the molecular mechanisms underlying obesity-associated adverse cardiac remodeling is critical for the identification of novel pathophysiological biomarkers and potential therapeutic targets. Circulating extracellular RNAs (ex-RNAs) regulate important biological processes and can serve as biomarkers of disease. This study aims to discover circulating extracellular RNAs (ex-RNAs) that serve as biomarkers of obesity-associated adverse cardiac remodeling in ACS survivors. METHODS:We analyzed extracellular RNA (ex-RNA) profiles in 296 survivors of acute coronary syndrome enrolled in the Transitions, Risks, and Actions in Coronary Events - Center for Outcomes Research and Education (TRACE-CORE) cohort. A total of 317 ex-RNAs were quantified, selected a priori based on prior findings from a large population-based study. We employed a two-step, mechanism-driven approach to identify ex-RNAs associated with echocardiographic phenotypes, including left atrial (LA) dimension, LA volume index, left ventricular (LV) ejection fraction, LV mass, and LV end-diastolic volume, then tested the relations of these ex-RNAs with obesity. We performed further bioinformatics analysis of the gene ontology categories and molecular pathways associated with predicted miRNA targets. RESULTS:We identified 45 ex-RNAs associated with at least one echocardiographic phenotype, of which miR-1185-1-3p, miR-550a-3p, and miR-885-5p were also associated with prevalent obesity. Bioinformatic analysis of their predicted gene targets (n=1,930) revealed enrichment in key pathways related to inflammation, fibrosis, and cellular toxicity, including Wnt/β-catenin signaling, TGF-β signaling, and hypoxia-inducible factor (HIF) signaling. Targets such as DICER1, VEGF, and EPO were implicated. Gene ontology analysis further highlighted associations with angiogenesis, FGF signaling, and interleukin pathways. CONCLUSIONS:Among ACS survivors, we observed that miR-1185-1-3p, miR-550a-3p, and miR-885-5p were associated with both echocardiographic markers of adverse cardiac remodeling and elevated BMI. Relevance for patients: miR-1185-1-3p, miR-550a-3p, and miR-885-5p were associated with echocardiographic phenotypes and obesity and are potential biomarkers for adverse cardiac remodeling in obesity.

Background:Timely detection of atrial fibrillation (AF) is critical for stroke prevention. Smartwatches are FDA-approved devices that can now aide in this detection. Objective:Investigate how socioeconomic status is associated with self-reported psychosocial outcomes, including anxiety, patient activation, and health-related quality of life in stroke survivors using smartwatch for AF detection. Methods:We analyzed data from the Pulsewatch study, a randomized controlled trial (NCT03761394). Participants in the intervention group wore a cardiac patch monitor in addition to a smartwatch for AF detection, whereas the control group wore only the cardiac patch monitor. Generalized anxiety disorder-7 scale, Consumer Health Activation Index and short-form health survey were completed to assess anxiety, patient activation, physical and mental health status at baseline, 14, and 44 days. We used a longitudinal linear regression model to examine changes in psychosocial outcomes in low (<$50K) vs. high (>$50K) income groups. Results:A total of 95 participants (average age 64.9± 9.1 years; 57.9% male; 89.5% non-Hispanic white) were included. History of renal disease (p-value 0.029), statin use (p-value 0.034), depression (p-value 0.004), and anxiety (p-value <0.001), were different between the income groups. In the adjusted model, the low-income group was associated with increased anxiety (β 2.75, p-value 0.0003), and decreased physical health status (β -5.07, p-value 0.02). There was no change identified in self-reported patient engagement and mental health status score. Conclusion:Our findings demonstrate that low SES is associated with worse self-reporting of physical health status, and this may influence psychosocial outcomes in smartwatch users.

BackgroundWhile ventricular tachycardia (VT) occurring during hospitalization for an acute myocardial infarction (AMI) increases mortality risk, its relationship with 30-day post-discharge rehospitalization has not been examined.MethodsUsing data from the Worcester Heart Attack Study, we examined the association between early (during the first 48 hours of admission) and late (after 48 hours of admission) VT with 30-day post-discharge all-cause and CVD-related rehospitalization while analytically controlling for several demographic and clinical factors.ResultsThe study population consisted of 3,534 patients who were hospitalized with an AMI between 2005 and 2015 (average age 67.2 years; 40.7% women); VT occurred in 452 patients (13.7%), with the majority (81.2%) occurring within 48 hours of admission. The 30-day all-cause rehospitalization rate was 17.3%, with 70.9% of the hospitalizations related to CVD. The odds of rehospitalization were 1.63 times (95%CI=0.99-2.69) and 1.12 times (95%CI=0.83-1.51) higher for patients with AMI who developed late VT and early VT, respectively, compared to patients who did not develop VT. The risk of rehospitalization among patients with late VT was higher (OR=2.22, (95%CI=0.79-6.26) in those with ST-segment-elevation compared to those with non-ST-segment-elevation AMI (OR=1.45, (95%CI=0.81-2.57); early VT was not associated with rehospitalization in patients with either AMI subtype. There was no significant association between the occurrence of VT and CVD-related rehospitalization.ConclusionPatients who develop late VT may experience a higher risk of 30-day rehospitalization following hospital discharge for AMI, especially among those with ST-segment-elevation AMI. Larger studies are needed to confirm our findings.

BACKGROUND:Cognitive impairment is strongly associated with atrial fibrillation (AF). Rate and rhythm control are the two treatment strategies for AF and the effect of treatment strategy on risk of cognitive decline and frailty is not well established. We sought to determine how treatment strategy affects geriatric-centered outcomes. METHODS:The Systematic Assessment of Geriatric Elements-AF (SAGE-AF) was a prospective, observational, cohort study. Older adults with AF were prospectively enrolled between 2016 and 2018 and followed longitudinally for 2 years. In a non-randomized fashion, participants were grouped by rate or rhythm control treatment strategy based on clinical treatment at enrollment. Baseline characteristics were compared. Longitudinal binary mixed models were used to compare treatment strategy with respect to change in cognitive function and frailty status. Cognitive function and frailty status were assessed with the Montreal Cognitive Assessment Battery and Fried frailty phenotype tools. RESULTS:972 participants (mean age = 75, SD = 6.8; 49% female, 87% non-Hispanic white) completed baseline examination and 2-year follow-up. 408 (42%) were treated with rate control and 564 (58%) with rhythm control. The patient characteristics of the two groups were different at baseline. Participants in the rate control group were older, more likely to have persistent AF, prior stroke, be treated with warfarin and have baseline cognitive impairment. After adjusting for baseline differences, participants treated with rate control were 1.5 times more likely to be cognitively impaired over 2 years (adjusted OR: 1.47, 95% CI:1.12, 1.98) and had a greater decline in cognitive function (adjusted estimate: -0.59 (0.23), p < 0.01) in comparison to rhythm control. Frailty did not vary between the treatment strategies. CONCLUSIONS:Among those who had 2-year follow-up in non-randomized observational cohort, the decision to rate control AF in older adults was associated with increased odds of decline in cognitive function but not frailty.

Background Multiple chronic conditions (MCCs) are common in patients hospitalized with acute myocardial infarction (AMI). We examined the association of 12 MCCs with the risk of a 30-day hospital readmission and/or dying within one year among those discharged from the hospital after an AMI. We also examined the five most prevalent pairs of chronic conditions in this population and their association with the principal study endpoints. Methods The study population consisted of 3,294 adults hospitalized with a confirmed AMI at the three major medical centers in central Massachusetts on an approximate biennial basis between 2005 and 2015. Patients were categorized as ≤1, 2-3, and ≥4 chronic conditions. Results The median age of the study population was 67.9 years, 41.6% were women, and 15% had ≤1, 32% had 2-3, and 53% had ≥4 chronic conditions. Patients with ≥4 conditions tended to be older, had a longer hospital stay, and received fewer cardiac interventional procedures. There was an increased risk for being rehospitalized during the subsequent 30 days according to the presence of MCCs, with the highest risk for those with ≥4 conditions. There was an increased, but attenuated, risk for dying during the next year according to the presence of MCCs. Individuals with diabetes/hypertension and those with heart failure/chronic kidney disease were at particularly high risk for developing the principal study outcomes. Conclusion Development of guidelines that include complex patients, particularly those with MCCs and those at high risk for adverse short/medium term outcomes, remain needed to inform best treatment practices.

ObjectivesTo examine the associations between catheter ablation treatment (CA) vs. medical management and cognitive impairment among older adults with atrial fibrillation (AF).MethodsAmbulatory patients who had AF, were ≥65-years-old, and were eligible to receive oral anticoagulation could be enrolled into the SAGE (Systematic Assessment of Geriatric Elements)-AF study from internal medicine and cardiology clinics in Massachusetts and Georgia between 2016 and 2018. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) tool at baseline, 1-, and 2 years. Cognitive impairment was defined as a MoCA score ≤ 23. Multivariate-adjusted logistic regression of longitudinal repeated measures was used to examine associations between treatment with CA vs. medical management and cognitive impairment.Results887 participants were included in this analysis. On average, participants were 75.2 ± 6.7 years old, 48.6% women, and 87.4% white non-Hispanic. 193 (21.8%) participants received a CA before enrollment. Participants who had previously undergone CA were significantly less likely to be cognitively impaired during the 2-year study period (aOR 0.70, 95% CI 0.50–0.97) than those medically managed (i.e., rate and/or rhythm control), even after adjusting with propensity score for CA. At the 2-year follow-up a significantly greater number of individuals in the non-CA group were cognitively impaired (MoCA ≤ 23) compared to the CA-group (311 [44.8%] vs. 58 [30.1%], p = 0.0002).ConclusionIn this 2-year longitudinal prospective cohort study participants who underwent CA for AF before enrollment were less likely to have cognitive impairment than those who had not undergone CA.

Asthma morbidity disproportionately impacts children from low-income and racial/ethnic minority communities. School-supervised asthma therapy improves asthma outcomes for up to 15 months for underrepresented minority children, but little is known about whether these benefits are sustained over time. We examined the frequency of emergency department (ED) visits and hospital admissions for 83 children enrolled in Asthma Link, a school nurse-supervised asthma therapy program serving predominantly underrepresented minority children. We compared outcomes between the year preceding enrollment and years one-four post-enrollment. Compared with the year prior to enrollment, asthma-related ED visits decreased by 67.9% at one year, 59.5% at two years, 70.2% at three years, and 50% at four years post-enrollment (all p-values< 0.005). There were also significant declines in mean numbers of total ED visits, asthma-related hospital admissions, and total hospital admissions. Our results indicate that school nurse-supervised asthma therapy could potentially mitigate racial/ethnic and socioeconomic inequities in childhood asthma.

Background Increasing ownership of smartphones among Americans provides an opportunity to use these technologies to manage medical conditions. We examine the influence of baseline smartwatch ownership on changes in self-reported anxiety, patient engagement, and health-related quality of life when prescribed smartwatch for AF detection. Method We performed a post-hoc secondary analysis of the Pulsewatch study (NCT03761394), a clinical trial in which 120 participants were randomized to receive a smartwatch-smartphone app dyad and ECG patch monitor compared to an ECG patch monitor alone to establish the accuracy of the smartwatch-smartphone app dyad for detection of AF. At baseline, 14 days, and 44 days, participants completed the Generalized Anxiety Disorder-7 survey, the Health Survey SF-12, and the Consumer Health Activation Index. Mixed-effects linear regression models using repeated measures with anxiety, patient activation, physical and mental health status as outcomes were used to examine their association with smartwatch ownership at baseline. Results Ninety-six participants, primarily White with high income and tertiary education, were randomized to receive a study smartwatch-smartphone dyad. Twenty-four (25%) participants previously owned a smartwatch. Compared to those who did not previously own a smartwatch, smartwatch owners reported significant greater increase in their self-reported physical health ( β = 5.07, P < 0.05), no differences in anxiety ( β = 0.92, P = 0.33), mental health ( β = −2.42, P = 0.16), or patient activation ( β = 1.86, P = 0.54). Conclusions Participants who own a smartwatch at baseline reported a greater positive change in self-reported physical health, but not in anxiety, patient activation, or self-reported mental health over the study period.

BackgroundAtrial fibrillation (AF) is a common cause of stroke, and timely diagnosis is critical for secondary prevention. Little is known about smartwatches for AF detection among stroke survivors. We aimed to examine accuracy, usability, and adherence to a smartwatch-based AF monitoring system designed by older stroke survivors and their caregivers. ObjectiveThis study aims to examine the feasibility of smartwatches for AF detection in older stroke survivors. MethodsPulsewatch is a randomized controlled trial (RCT) in which stroke survivors received either a smartwatch-smartphone dyad for AF detection (Pulsewatch system) plus an electrocardiogram patch or the patch alone for 14 days to assess the accuracy and usability of the system (phase 1). Participants were subsequently rerandomized to potentially 30 additional days of system use to examine adherence to watch wear (phase 2). Participants were aged 50 years or older, had survived an ischemic stroke, and had no major contraindications to oral anticoagulants. The accuracy for AF detection was determined by comparing it to cardiologist-overread electrocardiogram patch, and the usability was assessed with the System Usability Scale (SUS). Adherence was operationalized as daily watch wear time over the 30-day monitoring period. ResultsA total of 120 participants were enrolled (mean age 65 years; 50/120, 41% female; 106/120, 88% White). The Pulsewatch system demonstrated 92.9% (95% CI 85.3%-97.4%) accuracy for AF detection. Mean usability score was 65 out of 100, and on average, participants wore the watch for 21.2 (SD 8.3) of the 30 days. ConclusionsOur findings demonstrate that a smartwatch system designed by and for stroke survivors is a viable option for long-term arrhythmia detection among older adults at risk for AF, though it may benefit from strategies to enhance adherence to watch wear. Trial RegistrationClinicalTrials.gov NCT03761394; https://clinicaltrials.gov/study/NCT03761394 International Registered Report Identifier (IRRID)RR2-10.1016/j.cvdhj.2021.07.002

Background:The detection of atrial fibrillation (AF) in stroke survivors is critical to decreasing the risk of recurrent stroke. Smartwatches have emerged as a convenient and accurate means of AF diagnosis; however, the impact on critical patient-reported outcomes, including anxiety, engagement, and quality of life, remains ill defined.Objectives:To examine the association between smartwatch prescription for AF detection and the patient-reported outcomes of anxiety, patient activation, and self-reported health.Methods:We used data from the Pulsewatch trial, a 2-phase randomized controlled trial that included participants aged 50 years or older with a history of ischemic stroke. Participants were randomized to use either a proprietary smartphone-smartwatch app for 30 days of AF monitoring or no cardiac rhythm monitoring. Validated surveys were deployed before and after the 30-day study period to assess anxiety, patient activation, and self-rated physical and mental health. Logistic regression and generalized estimation equations were used to examine the association between smartwatch prescription for AF monitoring and changes in the patient-reported outcomes.Results:A total of 110 participants (mean age 64 years, 41% female, 91% non-Hispanic White) were studied. Seventy percent of intervention participants were novice smartwatch users, as opposed to 84% of controls, and there was no significant difference in baseline rates of anxiety, activation, or self-rated health between the 2 groups. The incidence of new AF among smartwatch users was 6%. Participants who were prescribed smartwatches did not have a statistically significant change in anxiety, activation, or self-reported health as compared to those who were not prescribed smartwatches. The results held even after removing participants who received an AF alert on the watch.Conclusion:The prescription of smartwatches to stroke survivors for AF monitoring does not adversely affect key patient-reported outcomes. Further research is needed to better inform the successful deployment of smartwatches in clinical practice.

To examine the association between anxiety, depression, or both, and clinical outcomes, including mortality, stroke, major bleeding, and hospitalizations, among older adults with atrial fibrillation (AF).

In older patients with atrial fibrillation (AF), physical, cognitive, and psychosocial limitations are prevalent. The prognostic value of these conditions for major bleeding is unclear. To determine whether geriatric conditions are prospectively associated with major bleeding in older patients with AF on anticoagulation. Multicenter cohort study with 2-year follow-up from 2016 to 2020 in Massachusetts and Georgia from cardiology, electrophysiology, and primary care clinics. Diagnosed with AF, age 65 years or older, CHA2DS2-VASc score of 2 or higher, and taking oral anticoagulant (n=1,064). A total of 6507 individuals were screened. A six-component geriatric assessment of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Main outcome was major bleeding adjudicated by a physician panel. At baseline, participants were, on average, 75.5 years old and 49% were women. Mean CHA2DS2-VASc score was 4.5 and the mean HAS-BLED score was 3.3. During 2.0 (± 0.4) years of follow-up, 95 (8.9%) participants developed an episode of major bleeding. After adjusting for key covariates and accounting for competing risk from death, cognitive impairment (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.02–2.56) and frailty (HR 2.77, 95% CI 1.38–5.58) were significantly associated with the development of major bleeding. In older patients with AF taking anticoagulants, cognitive impairment and frailty were independently associated with major bleeding.

BACKGROUND:As patient prices for many medications have risen steeply in the United States, patients may engage in cost-reducing behaviors (CRBs) such as asking for generic medications or purchasing medication from the Internet. OBJECTIVE:The objective of this study is to describe patterns of CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications among older adults with atrial fibrillation (AF) and examine participant characteristics associated with CRB. METHODS:Data were from a prospective cohort study of older adults at least 65 years with AF and a high stroke risk (CHA2DS2VASc ≥ 2). CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications were evaluated using validated measures. Chi-square and t tests were used to evaluate differences in characteristics across CRB, and statistically significant characteristics (P < 0.05) were entered into a multivariable logistic regression to examine factors associated with CRB. RESULTS:Among participants (N = 1224; mean age 76 years; 49% female), 69% reported engaging in CRB, 4% reported cost-related medication nonadherence, and 6% reported spending less on basic needs. Participants who were cognitively impaired (adjusted odds ratio 0.69 [95% CI 0.52-0.91]) and those who did not identify as non-Hispanic white (0.66 [0.46-0.95]) were less likely to engage in CRB. Participants who were married (1.88 [1.30-2.72]), had a household income of $20,000-$49,999 (1.52 [1.02-2.27]), had Medicare insurance (1.38 [1.04-1.83]), and had 4-6 comorbidities (1.43 [1.01-2.01]) had significantly higher odds of engaging in CRB. CONCLUSION:Although CRBs were common among older adults with AF, few reported cost-related medication nonadherence and spending less on basic needs. Patients with cognitive impairment may benefit from pharmacist intervention to provide support in CRB and patient assistance programs.