86 CHAPTER 6 ABSTRACT Introduction: Clinical guidelines recommend non-vitamin K antagonist oral anticoagulants (NOAC) over vitamin K antagonists (VKA) for stroke prevention in most patients with atrial fibrillation (AF). Frail elderly were underrepresented in the landmark NOAC trials, leaving a knowledge gap on the optimal anticoagulant management (VKA or NOAC) in this increasing population. The aim of the FRAIL-AF study is to assess whether switching from international normalised ratio (INR) guided VKA management to a NOAC based treatment strategy compared with continuing VKA management is safe in frail elderly patients with AF. Methods: The FRAIL-AF study is a pragmatic, multicentre, open-label, randomised controlled clinical trial. Frail elderly (age ≥75 years plus a Groningen Frailty Indicator score ≥3) who receive VKA treatment for AF in the absence of a mechanical heart valve or severe mitral valve stenosis will be randomised to switch to a NOAC based treatment strategy or to continue INR guided VKA management. Patients with severe renal impairment (estimated glomerular filtration rate <30mL/min/1.73 m2) will be excluded from randomisation. Based on existing trial evidence in non-frail patients, we will aim to explore whether NOAC treatment is superior to VKA therapy in reducing major or clinically relevant non-major bleeding events. Secondary outcomes include minor bleeding, the composite of ischaemic and haemorrhagic stroke, health-related quality of life and cost-effectiveness. The follow-up period for all subjects is twelve months. Ethics and dissemination: The protocol was approved by the Medical Research Ethics Committee of the University Medical Center Utrecht, the Netherlands and by the Central Committee on Research Involving Human Subjects, the Netherlands. All patients are asked written informed consent. Results are expected in 2022 and will be disseminated through peer-reviewed journals as well as presentations at national and international conferences.
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