Anticoagulating intermediate-risk AF: the first randomised answer favours a DOAC

The edition in brief

SINGLE-AF randomised 1,803 Korean patients with atrial fibrillation at intermediate stroke risk (CHA2DS2-VASc 1 in men, 2 in women) to a DOAC or no anticoagulation. The composite of stroke, systemic embolism, major bleeding or cardiovascular death at 24 months was 0.5% versus 1.5% (HR 0.31, 95% CI 0.10–0.94), with major bleeding similar between groups. Events were few and the trial was open-label, but it is the first randomised support for the class IIa recommendation. TRIC-I-HF randomised 360 older patients with symptomatic severe tricuspid regurgitation to transcatheter repair plus medical therapy or medical therapy alone; repair won on a hierarchical endpoint (win ratio 2.42) and halved death or heart failure hospitalisation through three years (HR 0.40). A pooled analysis in the European Heart Journal found MRA benefit depended on aldosterone before treatment: associated with better outcomes when aldosterone was high (HR 0.63) and worse when it was low (HR 1.66). This is hypothesis-generating and does not change prescribing. In the high bleeding risk subgroup of SELUTION DeNovo, a sirolimus-eluting balloon strategy had numerically fewer events than routine drug-eluting stents and allowed earlier antiplatelet withdrawal, but the subgroup was not powered.