Cardiology
children and teenagers to move more by taking them out for a walk and limiting time spent on social media and video games.”
Newer anticoagulants in the frail elderly The results of the FRAIL-AF trial were also presented in a Hot Line Session at ESC Congress. The study found that switching vitamin K antagonist (VKA) treatment to a non- vitamin K antagonist oral anticoagulant (NOAC) in frail elderly patients with atrial fibrillation is associated with more bleeding complications compared to continuing VKA treatment.5 In newly diagnosed patients with atrial fibrillation, NOACs are preferred over VKAs for the prevention of stroke.6
In atrial fibrillation
patients already using a VKA, ESC guidelines recommend considering switching to a NOAC, especially if the time in therapeutic range is not well-controlled despite good drug adherence.6 However, there are limited data on the comparison between VKAs and NOACs in frail elderly patients with atrial fibrillation7
and it is
unclear whether those currently managed with VKAs should be switched to NOACs. The FRAIL-AF trial investigated whether
switching VKA treatment to NOAC treatment was superior in terms of major and/or clinically relevant non-major bleeding complications in frail elderly patients with atrial fibrillation.8 Patients were at least 75 years of age, had a Groningen Frailty Indicator score of 3 or higher, and were currently managed with VKAs at one
All those hours of screen time in young people add up to a heavier heart, which we know from studies in adults raises the likelihood of heart attack and stroke. Children and teenagers need
to move more to protect their long-term health. Dr. Andrew Agbaje, University of Eastern Finland.
of the seven participating thrombosis centres in the Netherlands. Patients with severe renal impairment (estimated glomerular filtration rate below 30 mL/min/1.73 m2
) or with valvular atrial
fibrillation were excluded from randomisation. Participants were randomised in a 1:1
ratio to switch from a VKA to a NOAC or to continue a VKA. The choice of NOAC was left to the discretion of the treating physician. The follow-up duration was 12 months. The cause- specific hazard ratio (HR) was calculated for occurrence of the primary outcome which was major or clinically relevant non-major bleeding, whichever came first, accounting for death as a competing risk. Analyses followed the intention-to-treat
principle and were stratified for renal function. Secondary outcomes included thromboembolic events, defined as ischaemic stroke, transient ischaemic attack, and/or peripheral arterial thromboembolism. Between January 2018 and April 2022, a total of 1,330 patients were randomised. The mean age was 83 years and 38.8% were women. After 163
primary outcome events (101 in the switch arm, 62 in the continue arm), the trial was stopped for futility on advice from the Data Safety and Monitoring Board following a prespecified futility analysis. The HR for the primary outcome of major or
clinically relevant non-major bleeding was 1.69 (95% confidence interval [CI] 1.23 to 2.32) for switching to a NOAC relative to continuing a VKA. The HR for thromboembolic events was 1.26 (95% CI 0.60 to 2.61). Regarding secondary outcomes, 16
thromboembolic events occurred in the NOAC arm versus 13 in the VKA arm, yielding incidence rates of 2.6 (95% CI 1.5 to 4.3) and 2.1 (95% CI 1.1 to 3.6) per 100 patient-years, respectively. Study author Dr. Linda Joosten of the Julius
Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands said: “Switching VKA treatment to a NOAC in frail elderly patients with atrial fibrillation was associated with more bleeding complications compared to continuing a VKA. This higher bleeding risk with NOACs was not offset by a lower risk of thromboembolic events.”
Intravascular imaging vs angiography Late breaking research presented at ESC Congress also found that intravascular imaging- guided percutaneous coronary intervention (PCI) is associated with a lower rate of target lesion failure compared with angiography- guided PCI.9
Numerous randomised trials have
compared intravascular imaging-guided PCI with angiography-guided PCI. However, most of these prior trials have used intravascular ultrasound (IVUS). Optical coherence tomography (OCT) is a newer intravascular imaging modality that has enhanced resolution compared to IVUS. During Hot Line session 4 at ESC Congress 2023, two randomised trials of OCT-guided versus angiography-guided PCI were presented for the first time; the ILUMIEN IV trial in high-risk patients with complex lesions and the OCTOBER trial in bifurcation lesions. The authors of the current study performed a real-time updated network meta-analysis,
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www.clinicalservicesjournal.com I March 2024
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