Oral Anticoagulation for Patients With Atrial Fibrillation on Long-Term Dialysis

Survival Benefit of Anticoagulation Therapy in End Stage Kidney Disease Patients with Atrial Fibrillation: A Single Center Retrospective Study

Background and Objectives: Although the need for anticoagulation to prevent thromboembolism is increasing and non-vitamin K antagonist oral anticoagulants (NOACs) have been tried, there is still controversy about the efficacy of anticoagulation in patients with dialysis. Materials and Methods: We retrospectively analyzed the risk and benefit of anticoagulation in dialysis patients with atrial fibrillation (AF). We retrospectively analyzed all data of 89 patients who received dialysis therapy and were diagnosed with AF. Among them, 27 received anticoagulation (11 warfarin and 16 apixaban 2.5 mg twice a day), while 62 received no anticoagulation. Results: In multivariate Cox regression analysis, compared to no anticoagulation treatment, anticoagulation treatment was associated with a low incidence of all-cause mortality (hazard ratios (HR) 0.36; 95% confidence interval (CI) 0.15-0.88). Compared to no anticoagulation treatment, more anticoagulation treatment patients experienced severe bleeding (HR 4.67; 95% CI 1.26-17.25) and any bleeding (HR 2.79; 95% CI 1.01-7.74). Compared to no anticoagulation, warfarin treatment patients were associated with a low incidence of all-cause mortality (HR 0.26; 95% CI 0.09-0.81) and a high incidence of severe bleeding (HR 4.85; 95% CI 1.12-21.10). All-cause mortality and bleeding were not significantly different between no anticoagulation and apixaban treatment patients. Conclusions: In dialysis patients with AF, anticoagulation therapy is associated with an increased incidence of severe bleeding, but anticoagulation therapy is associated with a low incidence of all-cause mortality. Individualized anticoagulation therapy with careful bleeding monitoring is needed in dialysis patients with AF.

2021 Focused update of the 2017 consensus guidelines of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation

The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The Practice Guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of AF Better Care (ABC) pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" (COVID-19) pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.

A Scoping Review of Alternative Anticoagulation Strategies for Hemodialysis Patients with a Mechanical Heart Valve

INTRODUCTION

Patients with end-stage renal disease (ESRD) have high rates of cardiac valvulopathy but can develop contraindications for vitamin K antagonist (VKA) therapy. We explored the evidence for alternative anticoagulation strategies in patients with ESRD with a contraindication for VKA therapy.

METHODS

A scoping review was completed, searching MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Conference abstracts from inception to March 30, 2021. The study population was patients with ESRD who were on VKA therapy and developed a contraindication to VKA therapy use. All data regarding studies, patient characteristics, anticoagulation strategy, and clinical outcomes were summarized.

RESULTS

Twenty-three articles met inclusion criteria. These articles included 57 patients. Contraindications to VKA therapy included calcific uremic arteriolopathy (CUA) (n = 55) and warfarin-induced skin necrosis (n = 2). All studies were either case reports or case series. There were 10 anticoagulation strategies identified. Continuation of VKA therapy was associated with increased death and decreased rates of CUA resolution (80.0% and 10.0%, respectively), compared to apixaban (24.0% and 70.8%), subcutaneous (SC) low-molecular-weight heparin (LMWH) (14.3%, 85.7%), and SC unfractionated heparin (0.0%, 100.0%). While only 5 patient cases were reported with mechanical heart valves, SC LMWH use has been reported in this context with good outcomes.

CONCLUSIONS

In patients with ESRD who develop a contraindication to VKA therapy, several alternative anticoagulation strategies have been reported with superior outcomes to VKA continuation. While outcomes appear superior to continuation of VKA therapy, more data are required before definitive recommendations can be made for the patient with ESRD and a mechanical heart valve.

Antithrombotic Therapy for Chronic Kidney Disease Patients With Concomitant Atrial Fibrillation and Coronary Artery Disease

Background: Oral anticoagulants (OAC) plus antiplatelets is recommended for patients with atrial fibrillation (AF) and coronary artery disease (CAD) to reduce thromboembolism. However, there is limited evidence regarding antithrombotic therapy for patients with concomitant chronic kidney disease (CKD), AF, and CAD, especially those not undergoing percutaneous coronary intervention. We aimed to use real-world data assessing the efficacy and safety of antithrombotic regimens in this population.

Methods: We used a single-center database of 142,624 CKD patients to identify those receiving antithrombotic therapy for AF and CAD between 2010 and 2018. Patients taking warfarin or direct OAC (DOAC) alone were grouped in the OAC monotherapy (n = 537), whereas those taking OAC plus antiplatelets were grouped in the combination therapy (n = 2,391). We conducted propensity score matching to balance baseline covariates. The endpoints were all-cause mortality, major adverse cardiovascular events, and major bleedings.

Results: After 1:4 matching, the number of patients in OAC monotherapy and combination therapy were 413 and 1,652, respectively. Between the two groups, combination therapy was associated with higher risks for ischemic stroke (HR 2.37, CI 1.72–3.27), acute myocardial infarction (HR 6.14, CI 2.51–15.0), and hemorrhagic stroke (HR 3.57, CI 1.35–9.81). The results were consistent across CKD stages. In monotherapy, DOAC users were associated with lower risks for all-cause mortality, AMI, and gastrointestinal bleeding than warfarin, but the stroke risk was similar between the two subgroups.

Conclusions: For patients with concomitant CKD, AF and CAD not undergoing PCI, OAC monotherapy may reduce stroke and AMI risks. DOAC showed more favorable outcomes than warfarin.

Can direct oral anticoagulants be used in kidney transplant recipients?

BACKGROUND

Kidney transplant recipients(KTRs) are at an increased risk of venous thromboembolism (VTE) and atrial fibrillation(AF). Direct oral anticoagulants (DOACs) have shown important advantages over vitamin K antagonists; however, in KTRs, concerns regarding interactions and use in severe kidney disease may limit their use. This evaluation describes a large UK kidney transplant center's experience of DOACs in KTRs with CrCl > 15 mL/min.

METHODS

Electronic records were reviewed for all adult KTRs at Manchester University Foundation Trust Hospitals taking DOACs between January 2018 and October 2020 with VTE or AF. The primary outcome was trough and peak DOAC levels within the expected reference ranges and secondary outcomes included bleeding and thrombotic events.

RESULTS

In 31 KTRs taking DOACS, eight patients had a CrCl < 30 mL/min. Overall, 94% (62/66) of DOAC levels were within the recommended ranges. There were no thrombotic events and four bleeding events (two major and two clinically relevant non-major bleeds). The overall bleeding rate was 6.9 per 100 patient-years at risk.

CONCLUSIONS

There was no evidence of a significant interaction of apixaban or rivaroxaban with CNIs based on expected DOAC and CNI levels. Their use was found to be safe and effective with no VTE events and bleeding episodes similar to published trial data.

Diagnosis and Treatment of Intracardiac Thrombus

ABSTRACT

Intracardiac thrombi can occur in a variety of locations and are frequently encountered in clinical practice. Yet evidence-based guidance for clinicians managing patients with intracardiac thrombi is often limited. This review summarizes what is known regarding the prevalence of intracardiac thrombus, diagnostic strategies, clinical relevance, and treatment options, focusing on four specific types of thrombus for which recent research has shifted clinical understanding and treatment decisions: (1) left atrial appendage thrombus, (2) cardiac implantable electronic device lead thrombus, (3) bioprosthetic aortic valve thrombus, and (4) left ventricular thrombus. Additional studies, ideally prospective, randomized, and head-to-head in design, are needed to better inform best practices in patients with intracardiac thrombi.

The Association of Chronic Kidney Disease With Outcomes Following Percutaneous Left Atrial Appendage Closure

OBJECTIVES

The aim of this study was to investigate the associations of chronic kidney disease (CKD) and end-stage renal disease (ESRD) with in-hospital and short-term outcomes using a large national database representative of contemporary clinical practice.

BACKGROUND

CKD and ESRD are associated with increased risk for stroke and bleeding in patients with atrial fibrillation on oral anticoagulation. Left atrial appendage closure (LAAC) may provide a reasonable alternative for these patients; however, the impact of CKD and ESRD on in-hospital and short-term outcomes following LAAC remain largely unknown.

METHODS

The Nationwide Readmissions Database was used to identify LAAC procedures from 2016 to 2017 in patients with no CKD, CKD (stages I-V), and ESRD. Multivariable logistic regression models were used to assess in-hospital and short-term outcomes. The primary outcome was in-hospital mortality.

RESULTS

Of 21,274 patients who underwent LAAC during the study period, 3,954 (18.6%) had CKD and 571 (2.7%) had ESRD. ESRD was associated with increased risk for in-hospital mortality compared with no CKD (3.3% vs 0.4%; adjusted odds ratio: 6.48; 95% confidence interval: 3.35-12.50; P < 0.001) and CKD (3.3% vs 0.5%; adjusted odds ratio: 11.43; 95% confidence interval: 4.77-27.39; P < 0.001). CKD was associated with increased risk for in-hospital acute kidney injury or hemodialysis and stroke or transient ischemic attack. ESRD and CKD were associated with increased readmissions extending to 90 days compared with no CKD, and ESRD was associated with increased readmissions compared with CKD. There was no difference with respect to other in-hospital outcomes.

CONCLUSIONS

ESRD is associated with higher in-hospital mortality, and CKD is associated with higher rates of stroke or transient ischemic attack in patients undergoing LAAC. Further research is needed to assess the impact of CKD and ESRD on long-term outcomes in these patients.

Atrial Fibrillation in Patients with Chronic Kidney Disease

There is a bidirectional relationship between atrial fibrillation (AF) and chronic kidney disease (CKD), with multiple shared risk factors. This article discusses an integrated care approach toward the management of patients with AF, including those with CKD. There is an increasing risk of both ischemic stroke and bleeding with progressive deterioration of renal function, complicating the decision of optimal stroke prevention strategies among patients with AF and CKD. The optimal stroke prevention strategy in patients with AF and severe CKD remains uncertain. An individualized approach incorporating stroke and bleeding risk stratification is needed, especially in those with end-stage renal disease.

De-Escalation of Dual Antiplatelet Therapy in Patients With Acute Coronary Syndromes

BACKGROUND

Balancing the effects of dual antiplatelet therapy (DAPT) in the era of potent P2Y₁₂ inhibitors has become a cornerstone of acute coronary syndrome (ACS) management. Recent randomized controlled trials (RCTs) have investigated DAPT de-escalation to decrease the risk of bleeding outcomes.

OBJECTIVES

The aim of this study was to compare the efficacy and safety outcomes of various DAPT strategies in patients with ACS, including de-escalation from a potent P2Y₁₂ inhibitor to clopidogrel or low-dose prasugrel.

METHODS

MEDLINE and EMBASE were searched through January 2021 for RCTs investigating the efficacy and safety of DAPT in patients with ACS, and a network meta-analysis was conducted. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, and stroke. The primary bleeding outcome was trial-defined major or minor bleeding.

RESULTS

Our search identified 15 eligible RCTs, including 55,798 patients with ACS. De-escalation therapy was associated with reduced risk of primary bleeding outcomes (HR: 0.48 [95% CI: 0.30-0.77] vs clopidogrel; HR: 0.32 [95% CI: 0.20-0.52] vs ticagrelor; HR: 0.36 [95% CI: 0.24-0.55] vs standard-dose prasugrel; and HR: 0.40 [95% CI: 0.22-0.75] vs low-dose prasugrel) without negatively affecting primary efficacy outcomes. There were no significant differences in ischemic or bleeding outcomes between de-escalation to clopidogrel or low-dose prasugrel.

CONCLUSIONS

Compared with other established uses of DAPT, de-escalation was the most effective strategy for ACS treatment, resulting in fewer bleeding events without increasing ischemic events.

Anticoagulation in special patient populations with atrial fibrillation

Anticoagulation in patients with atrial fibrillation (AF) should be guided by considerations of the risk of thromboembolism, stroke, and bleeding as well as the patient's preference. Well-recognized scores have been developed to help the clinician in daily risk assessment, but there are several special patient populations for whom scores are not developed or validated. Furthermore, these patients were not adequately represented in the pivotal randomized trials for non-vitamin K antagonist oral anticoagulants (NOACs). In patients with cancer, the intrinsic hypercoagulable state has to be balanced against an increased risk of bleeding, and a dynamic concept should be applied, taking into account the cancer type, current disease state, therapeutic strategy, and patient-related factors, with NOACs playing an increasingly larger role. In women with planned pregnancy or already pregnant, NOACs should be avoided. However, accidental exposure during pregnancy should not lead to recommendations for pregnancy termination in view of current observational data. Whether patients on dialysis with AF benefit from anticoagulation at all is questionable. But if the decision for anticoagulation is made, NOACs may contribute to a more favorable risk-benefit profile than vitamin- K antagonists. Finally, patients on the ward deserve special considerations regarding periprocedural management of anticoagulation. Although for the majority of procedures a short discontinuation of oral anticoagulation seems appropriate, there are some low-bleeding-risk procedures that do not require cessation. The aim of the present review is to discuss the major particularities of these four patient subgroups and thus to facilitate the clinical decision-making.

Potent P2Y12 inhibitors versus Clopidogrel in elderly patients with acute coronary syndrome: Systematic review and meta-analysis

BACKGROUND

Potent P2Y12 inhibitors reduce cardiovascular events but increase bleeding in patients presenting with acute coronary syndrome (ACS). Elderly patients are at increased risk of bleeding and whether the benefit-risk ratio of potent P2Y12 inhibitors remains favorable is not known.

OBJECTIVES

To investigate the efficacy and safety of potent P2Y12 inhibitors versus clopidogrel in elderly patients with ACS.

METHODS

PUBMED and EMBASE were searched through July 2020 for randomized control trials (RCTs) or subgroup analyses of RCTs investigating potent P2Y12 inhibitors (prasugrel or ticagrelor) or clopidogrel in elderly (age ≥ 65 years) patients with ACS. The primary outcome was major adverse cardiovascular events (MACE).

RESULTS

Our search identified 9 RCTs with a total of 10,792 elderly patients. When compared with clopidogrel, potent P2Y12 inhibitors had similar risk of MACE (hazard ratio (HR): 0.94; 95%; confidence interval (CI) [0.85-1.06], P = .31, I² = 9%), all-cause mortality (HR: 0.89; 95% CI [0.74-1.07], P = .22, I² = 29%), reduced the risk of cardiovascular death (HR: 0.82; 95% CI [0.68-0.98], P = .03, I² = 16%) but increased the risk of major bleeding (HR: 1.27; 95% CI [1.04-1.56], P = .02, I² = 0%). In a subgroup analysis, ticagrelor reduced all-cause mortality (HR: 0.73; 95% CI [0.55-0.98]) and cardiovascular death (HR: 0.70; 95% CI [0.54-0.90]) compared with clopidogrel.

CONCLUSIONS

Among elderly patients with ACS, potent P2Y12 inhibitors reduce cardiovascular death but increase bleeding with no difference in MACE or all-cause death when compared with clopidogrel. Further RCTs are needed to refine P2Y12 inhibitor selection for elderly patients with ACS.

Racial and ethnic differences in left atrial appendage occlusion wait time, complications, and periprocedural management

PURPOSE

Non-white patients are underrepresented in left atrial appendage occlusion (LAAO) trials, and racial disparities in LAAO periprocedural management are unknown.

METHODS

We assessed sociodemographics and comorbidities of consecutive patients at our institution undergoing LAAO between 2015 and 2020, then in adjusted analyses, compared procedural wait time, procedural complications, and post-procedure oral anticoagulation (OAC) use in whites versus non-whites.

RESULTS

Among 109 patients undergoing LAAO (45% white), whites had lower CHA₂ DS₂ VASc scores, on average, than non-whites (4.0 vs. 4.8, p = .006). There was no difference in median time from index event (IE) or initial outpatient cardiology encounter to LAAO procedure (whites 10.5 vs. non-whites 13.7 months, p = .9; 1.9 vs. 1.8 months, p = .6, respectively), and there was no difference in procedural complications (whites 4% vs. non-whites 5%, p = .33). After adjusting for CHA₂ DS₂ VASc score, OAC use at discharge tended to be higher in whites (OR 2.4, 95% CI [0.9-6.0], p = .07). When restricting the analysis to those with prior gastrointestinal (GI) bleed, adjusting for CHA₂ DS₂ VASc score and GI bleed severity, whites had a nearly five-fold odds of being discharged on OAC (OR 4.6, 95% CI [1-21.8], p = 0.05). The association between race and discharge OAC was not mediated through income category (total mediation effect 19% 95% CI [-.04-0.11], p = .38).

CONCLUSION

Despite an increased prevalence of comorbidities amongst non-whites, wait time for LAAO and procedural complications were similar in whites versus non-whites. Among those with prior GI bleed, whites were nearly five-fold more likely to be discharged on OAC than non-whites, independent of income.

[Interdisciplinary aspects of oral anticoagulation with NOACs in atrial fibrillation]

Stroke prophylaxis with non-vitamin K-dependent oral anticoagulants (NOAKs) in patients with non-valvular atrial fibrillation (nvVHF) is now firmly established in routine clinical practice. The definition of nvVHF includes the absence of a mechanical heart valve and AF not associated with moderate- or high-grade mitral valve stenosis. The management of oral anticoagulation (OAC) requires a high degree of interdisciplinarity. Not least for this reason, uncertainties are repeatedly observed in practice, which can have far-reaching consequences for the individual patient. For this reason, a committee consisting of representatives from general medicine, geriatrics, cardiology, nephrology and neurology has gathered to identify aspects of practical relevance from the various disciplines and to jointly develop practical guidelines to improve therapy safety for patients in everyday life.

Oral Anticoagulant Treatment in Patients with Atrial Fibrillation and Chronic Kidney Disease

Over the past few decades, a series of innovative medicines have been developed in order to optimize anticoagulation therapy for atrial fibrillation (AF). As a result, a number of nonvitamin K antagonist oral anticoagulants (NOAC) that directly target the enzymatic activity of factor II and factor Xa have been successfully licensed providing a more predictable effect and better safety profile compared to conventional anticoagulants (heparins and vitamin K antagonists (VKAs)). However, comparative efficacy and safety data is limited in patients with advanced chronic kidney disease (i.e., CKD stage 4/5 and end stage renal disease) because patients with estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m² were actively excluded from landmark trials, thus representing a major clinical limitation for the currently available agents. However, the renal function of AF patients can be altered over time. On the other hand, patients with CKD have an increased risk of developing AF. This review article will provide an overview of current concepts and recent evidence guiding the clinical use of NOACs in patients with CKD requiring chronic anticoagulation, and the associated risks and benefits of treatment in this specific patient population.

Effectiveness and safety of rivaroxaban versus warfarin in Taiwanese patients with end-stage renal disease and nonvalvular atrial fibrillation: A real-world nationwide cohort study

BACKGROUND

The optimal anticoagulant for end-stage renal disease patients for stroke prophylaxis is unknown. The efficacy and safety of warfarin in this population are debatable. In addition, real-world evidence of direct oral anticoagulants in patients with end-stage renal disease is limited. The aim of this study was to evaluate the clinical outcomes of rivaroxaban compared with warfarin in Taiwanese patients with end-stage renal disease with nonvalvular atrial fibrillation in a real-world setting.

METHODS AND RESULTS

This was a retrospective population-based cohort study conducted using Taiwan's National Health Insurance Research Database. Patients with nonvalvular atrial fibrillation and end-stage renal disease who started on rivaroxaban or warfarin between February 2013 and September 2017 were eligible to participate in the study. The inverse probability of treatment weighting approach was used to balance baseline characteristics. Bleeding and thromboembolic outcomes were compared using competing risk analyses. The study population consisted of 3358 patients (173 and 3185 patients on rivaroxaban and warfarin, respectively). In the rivaroxaban group, 50.8%, 38.7%, and 10.4% of the patients received 10, 15, and 20 mg of the drug, respectively. The cumulative incidence of major bleeding was similar between the two groups; however, the gastrointestinal bleeding rate was lower in the rivaroxaban group (adjusted subdistribution hazard ratio [SHR]: 0.56, 95% confidence interval [CI]: 0.34-0.91) than in the warfarin group. Furthermore, the composite risk of ischemic stroke or systemic embolism was significantly lower in the rivaroxaban group (adjusted SHR: 0.36, 95% CI: 0.17-0.79). Similar findings were observed for patients who received 10 mg of rivaroxaban.

CONCLUSIONS

In Taiwanese patients with end-stage renal disease and nonvalvular atrial fibrillation, rivaroxaban may be associated with a similar risk of major bleeding but a lower risk of thromboembolism compared with warfarin. The potential benefit of 10 mg of rivaroxaban in this population requires further investigation.

Association of renin-angiotensin-aldosterone system inhibitors with mortality and testing positive of COVID-19: Meta-analysis

Some have hypothesized that the use of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin-receptor blockers (ARB) may modify susceptibility to coronavirus disease-2019 (COVID-19) in humans. Thus, we conducted two meta-analyses to investigate the effect of ACEI and ARB on mortality and susceptibility to COVID-19. Pubmed and EMBASE were searched through June 2020 to identify clinical trials that investigated the testing positive and in-hospital mortality rates for COVID-19 for those who were treated with ACEI and/or ARB and for those who were not treated with ACEI or ARB. The first analysis investigated the testing positive rate of COVID-19. The second analysis investigated the in-hospital mortality rate for patients with COVID-19. Three eligible studies for the first analysis and 14 eligible studies for the second analysis were identified. The first analysis demonstrated that the use of ACEI or ARB did not affect the testing positive rates (odds ratio [OR] [confidence interval [CI]] = 0.96 [0.88-1.04]; p = .69, OR [CI] = 0.99 [0.91-1.08]; p = 0.35, respectively). The second analysis showed that the use of ACEI and/or ARB did not affect in-hospital mortality (risk ratio [RR] 95% [CI]] = 0.88 [0.64-1.20], p = 0.42). The subgroup analysis by limiting studies of patients with hypertension showed ACEI and/or ARB use was associated with a significant reduction of in-hospital mortality compared with no ACEI or ARB use (RR [CI] = 0.66 [0.49-0.89], p = 0.004). Our analysis demonstrated that ACEI and/or ARB use was associated neither with testing positive rates of COVID-19 nor with mortality of COVID-19 patients.

Apixaban anti-Xa level monitoring in treatment of acute upper extremity deep vein thrombosis for patient on chronic hemodialysis: a case report

Background

Patients on dialysis are at higher risk of major bleeding and recurrent thrombosis creating acute venous thromboembolism (VTE) treatment challenges. DOACs represent an interesting option but there are concerns of bioaccumulation and increased bleeding risk. Anti-Xa trough levels may be used to monitor for bioaccumulation but there is little data.

Case presentation

We describe a case, a 51 yo female, 36 kg on hemodialysis with a provoked acute upper extremity deep vein thrombosis in whom body habitus and calciphylaxis contraindicated the use of standard therapy. She received apixaban 2.5 mg twice daily for 6 weeks. The apixaban anti-Xa trough levels were measured weekly 12 h after the morning dose and ranged from 58 to 84 ng/mL, similar to expected levels with normal renal function. There were no adverse events in the 3 months follow-up.

Conclusions

We saw no evidence of bioaccumulation indicating a potential role for low dose apixaban for acute VTE in dialysis patients.

Cardiovascular and Bleeding Outcomes with Anticoagulants across Kidney Disease Stages: Analysis of a National US Cohort

BACKGROUND

While direct oral anticoagulants (DOACs) are considered safe among patients without chronic kidney disease (CKD), the evidence is conflicting as to whether they are also safe in the CKD and end-stage kidney disease (ESKD) population. In this observational cohort study, we examined whether DOACs are a safe alternative to warfarin across CKD stages for a variety of anticoagulation indications.

METHODS

Individuals on DOACs or warfarin were identified from OptumLabs® Data Warehouse (OLDW), a longitudinal dataset with de-identified administrative claims, from 2010 to 2017. Cox models with sensitivity analyses were used to assess the risk of cardiovascular disease and bleeding outcomes stratified by CKD stage.

RESULTS

Among 351,407 patients on anticoagulation, 45% were on DOACs. CKD stages 3-5 and ESKD patients comprised approximately 12% of the cohort. The most common indications for anticoagulation were atrial fibrillation (AF, 44%) and venous thromboembolism (VTE, 23%). DOACs were associated with a 22% decrease in the risk of cardiovascular outcomes (HR 0.78, 95% CI: 0.77-0.80, p < 0.001) and a 10% decrease in the risk of bleeding outcomes (HR 0.90, 95% CI: 0.88-0.92, p < 0.001) compared to warfarin after adjustment. On stratified analyses, DOACs maintained a superior safety profile across CKD stages. Patients with AF on DOACs had a consistently lower risk of cardiovascular and bleeding events than warfarin-treated patients, while among other indications (VTE, peripheral vascular disease, and arterial embolism), the risk of cardiovascular and bleeding events was the same among DOAC and warfarin users.

CONCLUSION

DOACs may be a safer alternative to warfarin even among CKD and ESKD patients.

Safety of apixaban compared to warfarin in hemodialysis patients: Do antiplatelets make a difference?

BACKGROUND

Data on the safety of apixaban compared to warfarin in hemodialysis (HD) patients are accumulating, but the impact of concomitant antiplatelet use is unknown.

OBJECTIVES

Compare hemorrhagic risk and impact of antiplatelets in HD patients receiving oral anticoagulants (OAC).

METHODS

Retrospective, multi-center study of HD patients started on OAC inpatient over 5 years.

RESULTS

707 patients were included: 563 received warfarin, and 144 received apixaban. 197 had bleeding, most in the warfarin group (173 [30.1%] vs 24 [16.7%] in the apixaban group), P-value < .01). However, with concomitant antiplatelet use, frequencies were similar (31.4% vs 25.0%; P-value = .292). Cumulative incidence using bleeding as event of interest and death as competing risk showed higher rates of bleeding with warfarin. In a multivariate model, apixaban was associated with a lower hemorrhagic risk (hazard ratio [HR] 0.55 [95% confidence interval {CI} 0.35-0.86}). Apixaban showed lower hemorrhagic risk alone (HR 0.24, 95% CI 0.10-0.55) and similar risk when administered with antiplatelets (HR 0.93, 95% CI 0.55-1.56).

CONCLUSIONS

Apixaban is associated with less bleeding in HD patients compared to warfarin, but concomitant antiplatelet use may negate the safety advantage. Prospective trials are warranted to determine the impact of antiplatelets on apixaban safety.

Background characteristics and anticoagulant usage patterns of elderly non-valvular atrial fibrillation patients in the ANAFIE registry: a prospective, multicentre, observational cohort study in Japan

OBJECTIVE

To explore anticoagulant usage patterns stratified by stroke and bleeding risk in elderly patients with non-valvular atrial fibrillation (NVAF).

DESIGN

Prospective, multicentre, observational cohort study.

SETTING

The real-world All Nippon AF In the Elderly (ANAFIE) registry.

PARTICIPANTS

Japanese patients aged ≥75 years with NVAF (n=32 726).

OUTCOME MEASURES

The distribution of stroke and bleeding risk scores, and the selection of anticoagulant regimen for patients at high stroke and bleeding risk.

RESULTS

Overall, 18 185 (55.6%) patients had a high risk of stroke (CHADS2 score ≥3). Of these, 12 561 (38.4% of the total ANAFIE population) had a low bleeding risk (HAS-BLED ≤2) and 5624 (17.2%) had a high bleeding risk (HAS-BLED ≥3). Significant differences were noted between the high versus low bleeding risk groups in sex, height, weight, systolic blood pressure and rates of abnormality of lipid metabolism, gastrointestinal disease, cerebrovascular disorders, chronic kidney disease, angina pectoris, respiratory disease, primary malignant tumour, dementia and fall history within the past year (all p<0.0001). Patients with high stroke and bleeding risks had a lower anticoagulant usage rate versus the low bleeding risk group, and 8.7% and 5.8%, respectively, were not receiving any anticoagulant (p<0.0001). Patients in the high bleeding risk group had a higher usage of warfarin versus the low bleeding risk group (p<0.0001); more patients (14.0%) in the high bleeding risk group receiving warfarin had time in the therapeutic range <40%, versus those in the low bleeding risk group (11.6%, p=0.0146). Direct-acting oral anticoagulants (DOACs) were used less in the high bleeding risk group, without notable differences in the DOAC dose distribution between the two groups.

CONCLUSIONS

In elderly NVAF patients at high stroke risk, significant demographic and clinical differences were observed according to bleeding risk. Administration of low-dose DOACs was frequent, but the dose distribution was unaffected by bleeding risk.

TRIAL REGISTRATION NUMBER

UMIN000024006 (http://www.umin.ac.jp/).

Oral anticoagulation in chronic kidney disease with atrial fibrillation

Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist, amplifying the risk of cardiovascular events and mortality. In patients with CKD stage 3 and non-valvular AF, direct oral anticoagulants (DOACs) have shown, compared to vitamin K antagonists (VKA), equal or greater efficacy in the prevention of stroke and systemic embolism, and greater safety. There are no randomizedtrials of the efficacy and safety of DOACs and VKA in advanced CKD. On the other hand, observational studies suggest that DOACs, compared to warfarin, are associated with a lower risk of acute kidney damage and generation/progression of CKD. This paper reviews the epidemiological and pathophysiological aspects of the CKD and AF association, the evidence of the efficacy and safety of warfarin and ACODs in various stages of CKD with AF as well as the comparison between warfarin and ACODs in efficacy and anticoagulant safety, and in its renal effects.

Renal Disease and Atrial Fibrillation

Incidence and prevalence of atrial fibrillation (AF) and chronic kidney disease are increasing, and the two conditions commonly coexist. Renal impairment further increases the risk of ischemic stroke and systemic thromboembolism in patients with AF but also paradoxically predisposes to bleeding. Renal function should be monitored closely in patients with AF requiring oral anticoagulation therapy, particularly those receiving direct oral anticoagulants. Vitamin K antagonists can be used as part of a dose-adjusted anticoagulation regimen in patients with mild to moderate renal dysfunction. Dialysis-dependent patients taking vitamin K antagonists are at increased risk of sustaining major hemorrhage.

The effect of statins for asthma. A systematic review and meta-analysis

OBJECTIVE

To assess the effects of statins on asthma by systematically reviewing and conducting a meta-analysis on all clinical studies, including randomized controlled trials (RCTs) and observational studies, that examined the effects of statins on asthma.

METHODS

PubMed, EMBASE databases, and Cochrane reviews were searched to identify RCTs and observational studies, conducted through June 16, 2020, that assessed the effect of statins as a treatment for asthma. A meta-analysis was conducted using the following main outcomes: asthma control test (ACT), asthma control questionnaire (ACQ), pre- and post-bronchodilator forced expiratory volume in one second (FEV1), peak flow (PEF), and asthma exacerbation (asthma-related emergency department (ED) visits and hospitalization).

RESULTS

Our search revealed 11 RCTs and 8 observational studies that met the inclusion criteria. A meta-analysis demonstrated that statin treatment significantly improved ACT scores (mean difference: 1.61, P < 0.001) and ACQ scores (mean difference: -0.38, P < 0.001) compared to a placebo. Furthermore, statin treatment significantly reduced asthma-related ED visits (hazard ratio [HR], 95% confidence interval [CI], 0.83 [0.75-0.92], P < 0.001, number needed to treat [NNT], 5.9). However, statin treatment did not improve pulmonary function (FEV1 and PEF).

CONCLUSION

Our results suggest that statins have the potential to improve asthma control and reduce asthma exacerbation without any improvement in pulmonary function.

Supplemental data for this article can be accessed at publisher's website.

Direct Oral Anticoagulants in Atrial Fibrillation: Practical Considerations and Remaining Issues

Preventing thromboembolic events, while minimizing bleeding risks, remains challenging when managing patients with atrial fibrillation. Despite large and successful trial programs, several clinical concerns remain which commonly relate to fears of over- or underexposure to drugs and unfavorable outcomes. After a short summary of the main phase III trial findings, this short review discusses the evidence and clinical relevance of common clinical concerns (correct direct oral anticoagulant [DOAC] dosing; DOAC in moderate-to-severe renal impairment; and the relevance of fasting, nasogastric tube feeding, or high body mass index) on DOAC plasma levels. Finally, the need for specific DOAC antidotes will be addressed.

Hemodialysis-related low thrombogenicity measured by total thrombus-formation analysis system in patients undergoing percutaneous coronary intervention

BACKGROUND

Established antithrombotic therapies can increase bleeding risk, especially in hemodialysis (HD) patients. The Total Thrombus-formation Analysis System (T-TAS) is useful for evaluating thrombogenicity. The aim of this study was to examine the relationship between HD and thrombogenicity, or bleeding events in patients undergoing percutaneous coronary intervention (PCI).

METHODS

In this retrospective cohort study, 300 patients undergoing elective PCI were enrolled between April 2017 and March 2019. Blood samples obtained on the day of PCI were analyzed with T-TAS to compute the thrombus formation area under the curve (AUC; PL₁₈-AUC₁₀ for platelet chip; AR₁₀-AUC₃₀ for atheroma chip). The patients were divided into three groups according to estimated glomerular filtration rate (eGFR): 33 HD patients, 124 non-HD patients with eGFR <60 mL/min/1.73m², and 143 non-HD patients with eGFR ≥60. We examined the thrombogenicity and spontaneous bleeding events within 1-year post-PCI.

RESULTS

HD was significantly associated with both low PL₁₈-AUC₁₀ and AR₁₀-AUC₃₀ levels determined by T-TAS. Bleeding events defined by the Bleeding Academic Research Consortium criteria types 2, 3, or 5 occurred during follow-up in 27 patients (9.0%): 7 in HD, 10 in non-HD with eGFR <60, and 10 in non-HD with eGFR ≥60. Both T-TAS parameters in the patients with bleeding were lower compared with those in the patients without bleeding, and HD was significantly associated with 1-year bleeding events.

CONCLUSIONS

The results suggested that HD patients undergoing PCI might be a predictor for low thrombogenicity measured by T-TAS and 1-year bleeding risk.

Effect of Rivaroxaban or Apixaban in Atrial Fibrillation Patients with Stage 4-5 Chronic Kidney Disease or on Dialysis

BACKGROUND

Anticoagulant treatment in non-valvular atrial fibrillation (AF) patients with severe chronic kidney disease (CKD) or on dialysis remains a matter of debate. The object of this study was to quantify the benefit-risk profiles of rivaroxaban or apixaban versus warfarin in AF patients with stage 4-5 CKD or on dialysis.

METHOD

A comprehensive search of the Cochrane Library, PubMed, Ovid, and Google Scholar databases was performed for eligible studies that comparing the effect and safety of rivaroxaban or apixaban versus warfarin in AF patients with stage 4-5 CKD or on dialysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) were abstracted, and then pooled using a random-effects model.

RESULTS

A total of seven studies, one post hoc analysis of RCT and six observational cohorts, were included in this meta-analysis. Compared with warfarin use, the use of rivaroxaban or apixaban was significantly associated with reduced risks of all-cause death (HR = 0.82, 95% CI 0.72-0.93) and gastrointestinal bleeding (HR = 0.87, 95% CI 0.80-0.95). There were no significant differences in the risks of stroke or systemic embolism (rivaroxaban, HR = 0.71, 95% CI 0.43-1.19; apixaban, HR = 0.86, 95%CI 0.68-1.09) and major bleeding (rivaroxaban, HR = 0.96, 95% CI 0.64-1.45; apixaban, HR = 0.56, 95%CI 0.28-1.12).

CONCLUSIONS

Current evidence suggests that rivaroxaban or apixaban are safe and at least as effective as warfarin in patients with AF and stage 4-5 CKD or on dialysis.

Outcomes on safety and efficacy of left atrial appendage occlusion in end stage renal disease patients undergoing dialysis

BACKGROUND

In patients with end stage renal disease and atrial fibrillation (AF), undergoing chronic dialysis, direct oral agents are contraindicated and warfarin does not fully prevent embolic events while increasing the bleeding risk. The high hemorrhagic risk represents the main problem in this population. Aim of the study was to estimate the safety and efficacy for thromboembolic prevention of left atrial appendage (LAA) occlusion in a cohort of dialysis patients with AF and high hemorrhagic risk.

METHODS

Ninety-two dialysis patients with AF who underwent LAA occlusion were recruited. For comparative purposes, two cohorts of dialysis patients with AF, one taking warfarin (oral anticoagulant therapy, OAT cohort, n = 114) and the other not taking any OAT (no-therapy cohort, n = 148) were included in the study. Primary endpoints were (1) incidence of peri-procedural complications, (2) incidence of 2-year thromboembolic and hemorrhagic events, (3) mortality at 2 years. In order to evaluate the effect of the LAA occlusion on the endpoints with respect to the OAT and No-therapy cohorts, a multivariable Cox regression model was applied adjusted for possible confounding factors.

RESULTS

The device was successfully implanted in 100% of cases. Two major peri-procedural complications were reported. No thromboembolic events occurred at 2-year follow-up. The adjusted multivariable Cox regression model showed no difference in bleeding risk in the OAT compared to the LAA occlusion cohort in the first 3 months of follow-up [HR 1.65 (95% CI 0.43-6.33)], when most of patients were taking two antiplatelet drugs. In the following 21 months the bleeding incidence became higher in OAT patients [HR 6.48 (95% CI 1.32-31.72)]. Overall mortality was greater in both the OAT [HR 2.76 (95% CI 1.31-5.86)] and No-Therapy [HR 3.09 (95% CI 1.59-5.98)] cohorts compared to LAA occlusion patients.

CONCLUSIONS

The study could open the way to a non-pharmacological option for thromboembolic protection in dialysis patients with AF and high bleeding risk.

Oral Factor Xa Inhibitors versus Warfarin for the Treatment of Venous Thromboembolism in Advanced Chronic Kidney Disease

Introduction

Warfarin remains the preferred oral anticoagulant for the treatment of venous thromboembolism (VTE) in patients with advanced chronic kidney disease (CKD). Although the direct oral anticoagulants (DOACs) have become preferred for treatment of VTE in the general population, patients with advanced CKD were excluded from the landmark trials. Postmarketing, safety data have demonstrated oral factor Xa inhibitors (OFXais) such as apixaban and rivaroxaban to be alternatives to warfarin for the prevention of stroke and systemic embolism in patients with atrial fibrillation. However, it remains unknown if these safety data can be extrapolated to the treatment of VTE and CKD.

Methods

A retrospective cohort study from January 2013 to October 2019 was performed at NYU Langone Health. All adult patients with CKD stage 4 or greater, treated with anticoagulation for VTE, were screened. The primary outcome was tolerability of anticoagulant therapy at 3 months, defined as a composite of bleeding, thromboembolic events, and/or discontinuation rates. The secondary outcomes included bleeding, discontinuations, and recurrent thromboembolism.

Results

There were 56 patients evaluated, of which 39 (70%) received warfarin and 17 (30%) received an OFXai (apixaban or rivaroxaban). Tolerability at 3 months was assessed in 48/56 patients (86%). A total of 34/48 (71%) patients tolerated anticoagulation at 3 months, 12 (80%) in the OFXai arm, and 22 (67%) in the warfarin arm (p=0.498). There were 10/48 (21%) patients that experienced any bleeding events within 3 months, 7 on warfarin, and 3 on apixaban. Recurrence of thromboembolism within 3 months occurred in 3 patients on warfarin, with no recurrence in the OFXai arm. Discussion. OFXais were better tolerated compared to warfarin for the treatment of VTE in CKD, with lower rates of bleeding, discontinuations, and recurrent thromboembolism in a small cohort. Future prospective studies are necessary to confirm these findings.

Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy

Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.

Use of direct-acting oral anticoagulants in solid organ transplantation: A systematic review

The use of direct-acting oral anticoagulants (DOACs) has increased secondary to the mounting evidence for comparable efficacy and potentially superior safety to vitamin K antagonists (VKAs) in the general population. However, insufficient data regarding DOAC use in solid organ transplant (SOT) recipients and numerous pharmacokinetic and pharmacodynamic considerations limit their use in this highly selected patient population. A systematic review of recent clinical evidence on the safety and efficacy of DOACs compared to VKAs in SOT recipients was conducted. Additional considerations including transplant-specific strategies for DOAC reversal and common pharmacokinetic/pharmacodynamic concerns were also reviewed. Although current evidence is limited to single-center retrospective analyses, DOACs, especially apixaban, appear to be a safe and effective alternative to VKAs for SOT recipients with stable graft function and without drug-drug interactions. Reliable data on DOAC reversal at the time of transplant surgery are lacking, and clinicians should consider idarucizumab, andexanet alfa, and other non-specific reversal agents on an individual patient basis. There is no evidence supporting deviations from the Food and Drug Administration labeling recommendations for DOAC dosing in the setting of drug-drug interactions, obesity, and renal function, especially in patients on hemodialysis.

Non-vitamin K antagonist oral anticoagulants for stroke prevention in atrial fibrillation: safety issues in the elderly

INTRODUCTION

Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in patients with atrial fibrillation (AF). Since NOACs are predominantly used in the elderly with AF at high risk for stroke and bleeding and with comorbidities requiring polypharmacy, it is important to assess their safety and efficacy in this population.

AREAS COVERED

We review changes in pharmacokinetics and pharmacodynamics observed with senescence and the effect on NOACs and drug and food interactions. We also provide an update on challenges related to NOAC use in situations that increases the risk for bleeding or require temporary discontinuation and address practical issues in the elderly AF patients managed on NOACs. Clinical studies and trials with cardiovascular outcomes reported from January 1990 to August 2020 were identified through the Medline database using PubMed, Cochrane Library, and EMBASE database.

EXPERT OPINION

NOACs are highly effective in preventing stroke in AF patients with non-inferior or superior efficacy to warfarin, with reduced risk of major bleeding. However, in the older-elderly, evidence comes mainly from observational studies or extrapolation from studies in populations with minimal functional limitations or comorbidities. The high upfront cost and out-of-pocket expense for copayment or deductibles also limit the use of this effective therapy in a substantial number of patients. The cost reduction may further improve long-term use for NOACs in stroke prevention in elderly patients with AF.

Unprotected discharge: absence of stroke prevention strategies in patients with atrial fibrillation admitted for bleeding

PURPOSE

Patients with atrial fibrillation or flutter (AF) on anticoagulation (AC) for stroke prevention are at an increased risk of bleeding. A common clinical dilemma is deciding when to safely restart AC following a bleed. Although studies have shown better outcomes with re-initiation of AC after hemostasis, there are clinical barriers to restarting AC. Left atrial appendage occlusion (LAAO) is a safe and efficacious alternative for patients who are unable to tolerate AC following major bleeding. We aimed to evaluate the rate of stroke prevention strategies instituted at time of discharge in patients with AF on AC who had been hospitalized for a bleeding event.

METHODS

We retrospectively identified patients with AF on AC admitted for bleeding between January 2016 and August 2019. The type of AC, form of bleeding, and CHA₂DS₂VASc were collected. Stroke prevention strategies upon discharge and at 3 months were noted.

RESULTS

One hundred seventy-four patients with AF on AC were hospitalized with a bleeding event, of which 10.9% died. Among patients who survived, AC was restarted in 45.2% of patients, 9.7% were referred for LAAO, and 45.1% were discharged without stroke prevention strategy. At 3 months, 32.6% of patients still had no documented stroke prophylaxis. Those referred for LAAO had, on average, higher CHA₂DS₂VASc (5 ± 1 vs 4 ± 1, p = 0.007).

CONCLUSIONS

A significant number of patients with AF hospitalized for bleeding were discharged with no plan for stroke prophylaxis. Despite its safety and efficacy, LAAO appears to be an underutilized alternative in AF patients with high bleeding risk.

Stroke prevention strategies in high-risk patients with atrial fibrillation

Effective stroke prevention with oral anticoagulation (OAC) is the cornerstone of the management of patients with atrial fibrillation. The use of OAC reduces the risk of stroke and death. For most patients with atrial fibrillation without moderate or severe mitral valve stenosis or prosthetic mechanical heart valves, treatment options include vitamin K antagonists, such as warfarin, and non-vitamin K antagonist oral anticoagulants (NOACs). Although most guidelines generally recommend NOACs as the first-line OAC, caution is required in some groups of patients with atrial fibrillation at high risk of stroke and bleeding who have been under-represented or not studied in the randomized clinical trials on NOACs for stroke prevention. In addition to OAC, non-pharmacological, percutaneous therapies, including left atrial appendage occlusion, for stroke prevention have emerged, sometimes used in combination with catheter ablation for the treatment of the atrial fibrillation. High-risk groups of patients with atrial fibrillation include patients with end-stage renal failure (including those receiving dialysis), extremely old patients (such as those aged >80 years with multiple risk factors for bleeding), patients with dementia or those living in a long-term care home, patients with previous intracranial bleeding or recent acute bleeding (such as gastrointestinal bleeding), patients with acute ischaemic stroke and patients with an intracardiac thrombus. This Review provides an overview of stroke prevention strategies, including left atrial appendage occlusion, in patients with atrial fibrillation at high risk of stroke and bleeding.

Position paper on the safety/efficacy profile of direct oral anticoagulants in patients with chronic kidney disease. Consensus document from the SIN, FCSA and SISET

Direct oral anticoagulants (DOAC) are mostly prescribed to prevent cardioembolic stroke in patients with non-valvular atrial fibrillation (AF). An increasing number of guidelines recommend DOAC in AF patients with preserved renal function for the prevention of thromboembolism, and an increased use of DOAC in daily practice has been recorded also in elderly patients. Ageing is associated with a reduction in glomerular filtration rate, and impaired renal function, regardless of the cause, increases the risk of bleeding. Multiple medication use (polypharmacy) for treating superimposed co-morbidities is common in both elderly and chronic kidney disease (CKD) patients and drug-drug interaction may cause accumulation of DOAC, thereby increasing the risk of bleeding. The safety profile of DOAC in patients with CKD has not been defined with any certainty, particularly in those with severely impaired renal function or end stage renal disease. This has been due to the heterogeneity of studies and the relative paucity of data. This document reports the position of three Italian scientific societies engaged in the management of patients with atrial fibrillation who are treated with DOAC and present with CKD.

Direct oral anticoagulants in chronic kidney disease: an update

PURPOSE OF REVIEW

Direct oral anticoagulants (DOACs) are variably eliminated by the kidneys rendering their use potentially problematic in patients with chronic kidney disease (CKD) or necessitating appropriate dose adjustment.

RECENT FINDINGS

Both observational and limited randomized trial data for DOACs compared with no treatment or with warfarin for patients with atrial fibrillation on maintenance dialysis were recently published. In a randomized trial in patients on hemodialysis, there was no significant difference in vascular calcification between patients who received rivaroxaban with or without vitamin K2 or vitamin K antagonists. A randomized trial of apixaban versus warfarin was terminated owing to poor enrollment and preliminary results identified no difference in clinical outcomes between groups. However, valuable pharmacodynamic data will be forthcoming from that trial. In observational research, among patients newly diagnosed with atrial fibrillation, there were opposing trends in the associations of apixaban initiation versus no oral anticoagulation with ischemic versus hemorrhagic stroke and no association was present with the overall risk of stroke or embolism. In another study comparing apixaban with warfarin initiation, apixaban was associated with less bleeding. Regular-dose apixaban (5 mg twice daily) associated with reduced rates of ischemic stroke or systemic embolism, whereas no such association was present for those prescribed the reduced dose (2.5 mg twice daily).

SUMMARY

DOACs may be used after appropriate dose adjustment for an established clinical indication in patients with advanced CKD. Quality evidence for oral anticoagulation, with any specific agent or dose, for stroke prevention in hemodialysis continues to be lacking.

Effects of Anti-vitamin k oral anticoagulants on bone and cardiovascular health

Vitamin K antagonist oral anticoagulants (VKAs) have been proven over 50 years to be highly effective and acceptably safe in many settings and are still used by millions of people worldwide. The main concern about the safety of VKAs regards the risk of bleeding, but there is accumulation evidence of their potentially negative effects beyond hemostasis. Indeed, VKAs impair the action of several Vitamin-K Dependent Proteins (VKDP), such as Bone Gla protein, Matrix Gla protein, Gas6 Protein, Periostin and Gla-Ric Protein, involved in bone and vascular metabolism, thus exerting a detrimental effect on bone and vascular health. Indeed, although the evidence regarding this issue is not compelling, it has been shown that VKAs use decreases bone mass density, increases the risk of bone fractures and accelerates the process of vascular and valvular calcification. Vascular calcification is a major concern in Chronic Kidney Disease (CKD) patients, also in absence of VKAs, because of mineral metabolism derangement, chronic inflammation and oxidative stress. Direct Oral AntiCoagulants (DOACs) do not affect VKDP involved in vascular and valvular calcification, and do not induce calcific valve degeneration in animal models, being a possible alternative to AVK for CKD patients. However, the efficacy and safety of DOACs in this population, suggested by some recent observations, requires confirmation by dedicated, randomized study. We reviewed here the effects of VKAs in bone and vascular health as compared to DOACs, in order to provide the physicians with some data useful to wisely choose the most suitable anticoagulant for every patient.

Anticoagulation in Patients with End-Stage Renal Disease and Atrial Fibrillation: Confusion, Concerns and Consequences

End-stage renal disease (ESRD) patients have a higher prevalence of diabetes mellitus, hypertension, congestive heart failure and advanced age, along with an increased incidence of non-valvular atrial fibrillation (AF), thereby increasing the risk for cerebrovascular accidents. Systemic anticoagulation is therefore recommended in patients with ESRD with AF to reduce the risk and complications from thromboembolism. Paradoxically, these patients are at an increased risk of bleeding due to great degree of platelet dysfunction and impaired interaction between platelet and endothelium. Currently, CHA2DS2-VASc and Hypertension, Abnormal liver/kidney function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol (HAS-BLED) are the recommended models for stroke risk stratification and bleeding risk assessment in patients with AF. There is conflicting data regarding benefits and risks of medications such as antiplatelet agents, warfarin and direct oral anticoagulants in ESRD patients with AF. Moreover, there is no randomized controlled trial data to guide the clinical decision making. Hence, a multi-disciplinary approach with annual re-evaluation of treatment goals and risk-benefit assessment has been recommended. In this article, we review the current recommendations with risks and benefits of anticoagulation in patients with ESRD with AF.

Clinical and Prodromal Ocular Symptoms in Coronavirus Disease: A Systematic Review and Meta-Analysis

Purpose

This systematic review aimed to determine currently reported clinical and prodromal ocular symptoms in patients with coronavirus disease 2019 (COVID-19).

Methods

An online article search was performed in PubMed and EMBASE. Altogether 15 studies (retrospective, prospective, or case studies) involving 1533 patients with COVID-19, reporting on ocular symptoms, and with outcome data available were identified. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines were followed. Study-specific estimates (incidence rates of ocular symptoms in patients with COVID-19) of cases were combined using one-group meta-analysis in a random-effects model.

Results

Of all included studies, 11.2% (95% confidence interval, 5.5-16.9; 78/1526 cases) reported ocular symptoms. The most common ocular finding was conjunctivitis. Prodromal ocular symptoms occurred in 12.5% (13/104 cases) of patients with COVID-19. Positive real-time polymerase chain reaction results were obtained for 16.7% (10/60 cases) of conjunctival samples and 0% (0/17 cases) of tear samples. Twelve ocular conjunctival swab samples tested positive for SARS-CoV-2. Ten cases were from subjects showing ocular symptoms (16.7%, 10/60 cases), and the remaining two cases were from subjects without ocular manifestation (1.8%, 2/113 cases). Limitations included the short study period, small sample size, findings were limited to the Asian population, only seven articles included ophthalmologic examination details, and there is currently no consensus on COVID-19 management.

Conclusions

Ocular symptoms may occur in the presymptomatic phase as a prodromal symptom (12.5%, 13/104 cases), suggesting the possibility of viral transmission from the conjunctiva.

Anticoagulation With or Without Antiplatelet Therapy Following Transcatheter Aortic Valve Replacement for Patients With Atrial Fibrillation: A Meta-Analysis

BACKGROUND

Although current guidelines recommend oral anticoagulants (OAC) with or without antiplatelet therapy (APT) following transcatheter aortic valve replacement (TVAR) in patients with an indication for long-term anticoagulation therapy, the optimal antithrombotic strategy remains unknown in these population. Herein, we conducted a meta-analysis comparing the outcome of OAC alone versus OAC with APT following TAVR in patients with atrial fibrillation (AF).

METHODS

MEDLINE and EMBASE were searched through May 2020 to identify clinical trials that investigated OAC alone versus OAC with APT following TAVR in patients with AF. From each study, we extracted the hazard ratios (HRs) or risk ratios of major or life threatening bleeding, stroke, all-cause mortality and cardiovascular mortality.

RESULTS

1 randomized controlled trial and 3 observational studies were identified, which enrolled a total of 2032 patients with AF who underwent TAVR assigned to the OAC group (n = 722) or OAC with APT group (n = 1310). Pooled analyses demonstrated the rate of major or life threatening bleeding was significantly lower in the OAC group compared to the OAC with APT group (HR [95% Confidence Interval [CI] = 0.54 [0.38-0.77], P = .0006]). However, the rate of stroke was similar in both groups (HR [95% CI] = 1.22 [0.80-1.87], P = .36). All-cause and cardiovascular mortalities were also similar in both groups.

CONCLUSIONS

We observed that OAC with APT following TAVR in patients with AF increased the risk of bleeding compared to OAC alone without decreasing the risk of stroke.

Oral anticoagulation and cardiovascular outcomes in patients with atrial fibrillation and chronic kidney disease in Asian Population, Data from the COOL-AF Thailand registry

BACKGROUND AND OBJECTIVES

Patients with AF and chronic kidney disease(CKD) encountered increased risks of stroke, bleeding, morbidity, and overall mortality. Oral anticoagulation in these populations definitely enhances major bleeding but the benefit of stroke reduction remained inconclusive.The aim of this study is to evaluate the effect of oral anticoagulation (OAC) on the 2-year cardiovascular outcomes in patients with AF and CKD.

METHOD

NVAF patients were consecutively enrolled from 27 hospitals located all across Thailand.Baseline demographic and clinical data were collected within 6 months from enrollment.GFR was calculated using CKD-EPI formula. CKD patients were defined as GFR less than 60 mL/min/1.73 m² according to KDOQI of the National Kidney Foundation. Clinical outcomes included ischemic stroke or transient ischemic attack (TIA) and major bleeding.

RESULTS

At 25.7 ± 10.6 months of follow up, we identified 2538 patients with complete renal follow-up data. Among these were 1594 patients with CKD (stage 3-5) and 944 patients without CKD. The rate of ischemic stroke in patients with and without CKD were 3.7% and 1.7% respectively (p = 0.004),the rate of major bleeding was 5.6 and 3.5% accordingly (p = 0.015) and, likewise, the death rate was substantially high in patients with CKD (10.0% and 6.5%, p = 0.02). The rate of ischemic stroke/TIA in patients with CKD who were and were not on OAC did not differ significantly, 3.6% and 4.2% respectively (p = 0.602). NOAC and warfarin did not differ significantly in the propensity score-matched rate of both ischemic stroke/TIA (0 and 1.2%, p = 0.554) and major bleeding (3.3% and 7.4%, p = 0.122).The net clinical benefit of NOAC over warfarin was 2.153 per 100-patient years.

CONCLUSIONS

COOL AF registry demonstrated that AF patients with CKD had increased risks of ischemic stroke/TIA, major bleeding and death. The benefit of stroke/TIA reduction was not significantly evident for either warfarin or NOAC. However, NOAC was associated with the positive net clinical benefit over no OAC.

Necessity of Antiaggregation and Anticoagulation and Its Prognostic Impact: A Cardiologist's View

BACKGROUND

In modern cardiology, anticoagulation and antiaggregation are key components of current treatment strategies. However, in patients treated with anticoagulation and antiplatelet substances, bleeding is a major risk.

FINDINGS

In all major cardiovascular diseases, a multitude of studies have shown a positive impact of antithrombotic treatment on cardiovascular death. In patients with higher bleeding risks, recent studies showed the safety of reducing the period of dual antiplatelet therapy (DAPT), i.e., after percutaneous coronary intervention. In patients with coronary artery disease and atrial fibrillation (AF), triple therapy including DAPT and anticoagulation is associated with very high bleeding risks. However, recently published data showed the safety of direct oral anticoagulants (DOACs) and P2Y12 inhibitors only compared to vitamin K antagonist (VKA) and DAPT. Anticoagulation in nonvalvular AF reduces major cerebrovascular ischemic events. However, the inherent cerebrovascular bleeding risk is an important concern of this treatment. With the advent of DOACs, this risk could be reduced compared to VKA. Furthermore, anticoagulation and antiaggregation are crucial after treatment of valve disease, both after surgical and interventional procedures. Even in heart failure, new data show benefits using antithrombotic substances.

CONCLUSIONS

Anticoagulation and antiaggregation are of major prognostic relevance in cardiovascular diseases. However, the inherent bleeding risk has to be considered.

Position paper on the safety/efficacy profile of Direct Oral Anticoagulants in patients with Chronic Kidney Disease: Consensus document of Società Italiana di Nefrologia (SIN), Federazione Centri per la diagnosi della trombosi e la Sorveglianza delle terapie Antitrombotiche (FCSA) and Società Italiana per lo Studio dell'Emostasi e della Trombosi (SISET)

Direct oral anticoagulants (DOAC) are mostly prescribed to prevent cardioembolic stroke in patients with non-valvular atrial fibrillation (AF). An increasing number of guidelines recommend DOAC in AF patients with preserved renal function for the prevention of thromboembolism and an increased use of DOAC in daily practice is recorded also in elderly patients. Aging is associated with a reduction of glomerular filtration rate and impaired renal function, regardless of the cause, increases the risk of bleeding. Multiple medication use (polypharmacy) for treating superimposed co-morbidities is common in both elderly and chronic kidney disease (CKD) patients and drug-drug interaction may cause accumulation of DOAC, thereby increasing the risk of bleeding. There is uncertainty on the safety profile of DOAC in patients with CKD, particularly in those with severely impaired renal function or end stage renal disease, due to the heterogeneity of studies and the relative paucity of data. This document reports the position of three Italian scientific societies engaged in the management of patients with atrial fibrillation who are treated with DOAC and present with CKD.