Joosten LPT, van Doorn S, van de Ven PM, et al. Safety of Switching From a Vitamin K Antagonist to a Non-Vitamin K Antagonist Oral Anticoagulant in Frail Older Patients With Atrial Fibrillation: Results of the FRAIL-AF Randomized Controlled Trial. Circulation. 2024 Jan 23;149(4):279-289. doi: 10.1161/CIRCULATIONAHA.123.066485. Epub 2023 Aug 27. (Original study)

BACKGROUND: There is ambiguity whether frail patients with atrial fibrillation managed with vitamin K antagonists (VKAs) should be switched to a non-vitamin K oral anticoagulant (NOAC).

METHODS: We conducted a pragmatic, multicenter, open-label, randomized controlled superiority trial. Older patients with atrial fibrillation living with frailty (=75 years of age plus a Groningen Frailty Indicator score =3) were randomly assigned to switch from international normalized ratio-guided VKA treatment to an NOAC or to continued VKA treatment. Patients with a glomerular filtration rate <30 mL·min-1·1.73 m-2 or with valvular atrial fibrillation were excluded. Follow-up was 12 months. The cause-specific hazard ratio was calculated for occurrence of the primary outcome that was a major or clinically relevant nonmajor bleeding complication, whichever came first, accounting for death as a competing risk. Analyses followed the intention-to-treat principle. Secondary outcomes included thromboembolic events.

RESULTS: Between January 2018 and June 2022, a total of 2621 patients were screened for eligibility and 1330 patients were randomly assigned (mean age 83 years, median Groningen Frailty Indicator score 4). After randomization, 6 patients in the switch-to-NOAC arm and 1 patient in the continue-with-VKA arm were excluded due to the presence of exclusion criteria, leaving 662 patients switched from a VKA to an NOAC and 661 patients continued VKAs in the intention-to-treat population. After 163 primary outcome events (101 in the switch arm, 62 in the continue arm), the trial was stopped for futility according to a prespecified futility analysis. The hazard ratio for our primary outcome was 1.69 (95% CI, 1.23-2.32). The hazard ratio for thromboembolic events was 1.26 (95% CI, 0.60-2.61).

CONCLUSIONS: Switching international normalized ratio-guided VKA treatment to an NOAC in frail older patients with atrial fibrillation was associated with more bleeding complications compared with continuing VKA treatment, without an associated reduction in thromboembolic complications.

REGISTRATION: URL: https://eudract.ema.europa.eu; Unique identifier: 2017-000393-11. URL: https://eudract.ema.europa.eu; Unique identifier: 6721 (FRAIL-AF study).

Discipline Area Score
Cardiology 7 / 7
Geriatrics 7 / 7
Hemostasis and Thrombosis 6 / 7
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Internal Medicine 6 / 7
Comments from MORE raters

Cardiology rater

Interesting data. In patients with frailty, if control INR is stable and optimal, the study shows it is better to stay with coumadin than switching to a NOAC.

Cardiology rater

This paper answers a very important question: when a frail elderly person with AF is doing well on warfarin, keep them on it. Despite the greater convenience of DOACs, switching to one will result in poorer outcomes.

Hemostasis and Thrombosis rater

These findings are unexpected and must be put into context with other knowledge about these medications and populations (including medication interactions, access to testing/monitoring resources, etc).

Hemostasis and Thrombosis rater

The bleeding difference occurs very late - many months - after the switch. The explanation is far from evident and raises questions as to applicability.

Internal Medicine rater

Not as relevant in countries in which DOACs predominate, but a very important trial re safety of switching OAC drugs from VKA to DOAC.

Internal Medicine rater

This was an underpowered negative study. Although the trends suggest that continuing VKA may be more efficacious and/or safer than switching to DOAC therapy, none of the OR were statistically significant, so no definitive conclusions can be drawn from these data. One needs to balance this with the convenience of eliminating INR draws in the frail elderly. More data are needed.
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