194 SUMMARY GENERAL INTRODUCTION In Chapter 1, the general introduction, the case of Mrs. de Jong is introduced to illustrate that there are important gaps in the evidence on the management of atrial fibrillation (AF), notably in frail older patients. Importantly, it is unclear whether frail older patients with AF can safely switch from a vitamin K antagonist (VKA) to a non-VKA oral anticoagulant (NOAC). Both VKAs and NOACs are oral anticoagulants prescribed to reduce the risk of ischaemic stroke in patients with AF. An important side effect of oral anticoagulants, inherent to their action, is an increased risk of bleeding. The CHA2DS2-VASc model is widely used to balance the efficacy and safety of oral anticoagulants, though its accuracy remains in debate. Furthermore, the importance of conducting high-quality research, including randomised controlled trials (RCTs), in the frail older population is highlighted in the general introduction. After all, evidence from a relatively young and vital population cannot simply be generalised to frail elderly. PATHOPHYSIOLOGY OF INCREASED ISCHAEMIC STROKE RISK IN PATIENTS WITH ATRIAL FIBRILLATION In Chapter 2, it is argued that it is not only blood stasis in fibrillating atria that plays a role in the development of emboli that can cause ischaemic stroke, but also the other two aspects of Virchow’s triad for thrombogenesis: changes in blood constituents and changes in walls of blood vessels and atria. This supports the view that AF should be considered a systemic cardiovascular disease rather than solely a hearth rhythm disorder. This is in line with the ‘Atrial Fibrillation Better Care (ABC) pathway’ as incorporated in the most recent guidelines of the European Society of Cardiology,1 and investigated in practice through, for example, the ALL-IN trial in which was demonstrated that integrated AF care in patients with AF led to a 45% reduction in all-cause mortality.2 To further improve AF management, more studies should be performed into coagulation mechanisms that are related to the occurrence of AF itself and its association with ischaemic stroke. SEX- AND AGE SPECIFIC ASSOCIATION OF NEW-ONSET ATRIAL FIBRILLATION WITH MORTALITY IN COVID-19 PATIENTS Within one month after the occurrence of a respiratory tract infection, such as coronavirus disease 2019 (COVID-19), the risk of cardiovascular disease (including the development of AF) was 1.5-5 times higher.3 Moreover, in patients hospitalised with COVID-19 during the first wave in 2020 new-onset AF was associated with increased risk of mortality.4–6 In Chapter 3 data of a large international multicentre registry study (CAPACITY-COVID) were used to investigate how this increased risk of mortality in
RkJQdWJsaXNoZXIy MTk4NDMw