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Tanaka A, Inaguma D, Shinjo H, Murata M, Takeda A. Presence of Atrial Fibrillation at the Time of Dialysis Initiation Is Associated with Mortality and Cardiovascular Events. Nephron Clin Pract 2016; 132:86-92. [DOI: 10.1159/000443314] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 12/10/2015] [Indexed: 11/19/2022] Open
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Affiliation(s)
- Marcello Tonelli
- From Department of Medicine, University of Calgary, AB, Canada (M.T.); Department of Medicine and Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, and Howard Hughes Medical Institute, Chevy Chase, MD (S.A.K..); and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston (R.T.)
| | - S. Ananth Karumanchi
- From Department of Medicine, University of Calgary, AB, Canada (M.T.); Department of Medicine and Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, and Howard Hughes Medical Institute, Chevy Chase, MD (S.A.K..); and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston (R.T.)
| | - Ravi Thadhani
- From Department of Medicine, University of Calgary, AB, Canada (M.T.); Department of Medicine and Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, and Howard Hughes Medical Institute, Chevy Chase, MD (S.A.K..); and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston (R.T.)
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203
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Lee M, Saver JL, Hong KS, Wu YL, Huang WH, Rao NM, Ovbiagele B. Warfarin Use and Risk of Stroke in Patients With Atrial Fibrillation Undergoing Hemodialysis: A Meta-Analysis. Medicine (Baltimore) 2016; 95:e2741. [PMID: 26871818 PMCID: PMC4753914 DOI: 10.1097/md.0000000000002741] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In spite of the substantial burden of atrial fibrillation and associated elevated ischemic stroke risk in patients undergoing hemodialysis, the role of warfarin in these high-risk patients remains uncertain. Our objective was to clarify the association between warfarin use and risk of stroke for patients with atrial fibrillation undergoing dialysis.PubMed and Embase from January 1966 to January 2015 were searched to identify relevant studies. Inclusion criteria were cohort studies, patients with atrial fibrillation undergoing hemodialysis, and reported quantitative estimates of the multivariate adjusted relative risk (RR) and 95% confidence interval (CI) for future stroke associated with warfarin use. We identified 8 studies, with a total of 9539 participants and 706 stroke events. Three studies reported total stroke as primary endpoint and other studies reported ischemic stroke as primary endpoint. Pooling the results showed that warfarin use was associated with higher risk of any stroke (RR 1.50, 95% CI: 1.13-1.99). By stroke type, warfarin was not significantly linked to risk of ischemic stroke (RR 1.01, 95% CI: 0.65-1.57, P = 0.97), but was related to greater hemorrhagic stroke risk (RR 2.30, 95% CI: 1.62-3.27). Warfarin heightened overall bleeding risk (RR 1.27, 95% CI: 1.03-1.56), but not death (RR 0.67, 95% CI: 0.37-1.21).Among patients with atrial fibrillation undergoing hemodialysis, use of warfarin is associated with a higher risk of hemorrhagic stroke, but did not increase overall mortality.
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Affiliation(s)
- Meng Lee
- From the Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Puzi, Taiwan (ML and YLW); Stroke Center and Department of Neurology, Geffen School of Medicine, University of California, Los Angeles, CA (JLS, NMR); Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, South Korea (KSH); Division of Nephrology, Department of Internal Medicine, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan (WHH); Department of Neurosciences, Medical University of South Carolina (BO), Charleston, SC
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Schwartzenberg S, Lev EI, Sagie A, Korzets A, Kornowski R. The Quandary of Oral Anticoagulation in Patients With Atrial Fibrillation and Chronic Kidney Disease. Am J Cardiol 2016; 117:477-82. [PMID: 26721651 DOI: 10.1016/j.amjcard.2015.10.065] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 10/30/2015] [Accepted: 10/30/2015] [Indexed: 11/16/2022]
Abstract
Compared to patients with normal renal function, the prevalence of atrial fibrillation (AF) in chronic kidney disease (CKD) is increased, as is consequently the stroke prevalence in these patients. This increased risk of stroke in patients with CKD is caused not only by the increased prevalence of AF, but also by associated co-morbidities, and inherent platelet and vascular dysfunction. Paradoxically, imbalance in the same factors also increases the bleeding risk, imposing a dilemma as to whether anticoagulation should be prescribed or deferred, particularly in patients with end-stage renal disease (ESRD), in whom the bleeding diathesis and thromboembolic predisposition are most recalcitrant. Unfortunately, it is in this vulnerable population, in whom therapeutic options are most limited, that evidence-based studies relating to stroke prophylaxis are scarce, discordant and based only on registry observations. Pending randomized controlled studies on this issue, we will review important epidemiologic data and major recent registry-based studies that the clinician has to weigh when making the best decision on the issue of the prophylactic use of warfarin in patients with CKD with AF, focusing on patients with end-stage renal disease.
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Affiliation(s)
- Shmuel Schwartzenberg
- Department of Cardiology, Rabin Medical Center, Beilinson & Hasharon Hospitals, Petach Tikva, Israel.
| | - Eli I Lev
- Department of Cardiology, Rabin Medical Center, Beilinson & Hasharon Hospitals, Petach Tikva, Israel
| | - Alexander Sagie
- Department of Cardiology, Rabin Medical Center, Beilinson & Hasharon Hospitals, Petach Tikva, Israel
| | - Asher Korzets
- Department of Nephrology, Rabin Medical Center, Beilinson & Hasharon Hospitals, Petach Tikva, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Beilinson & Hasharon Hospitals, Petach Tikva, Israel
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Macle L, Cairns JA, Andrade JG, Mitchell LB, Nattel S, Verma A. The 2014 Atrial Fibrillation Guidelines Companion: A Practical Approach to the Use of the Canadian Cardiovascular Society Guidelines. Can J Cardiol 2016; 31:1207-18. [PMID: 26429352 DOI: 10.1016/j.cjca.2015.06.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 06/10/2015] [Accepted: 06/10/2015] [Indexed: 12/19/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Program has generated a comprehensive series of documents regarding the management of atrial fibrillation (AF) between 2010 and 2014. The guidelines provide evidence-based consensus management recommendations in a broad range of areas. These guidelines have proven useful in informing clinical practice, but often lack detail in specifications related to practical application, particularly for areas in which the evidence base is limited or conflicting. Based on feedback from the community, the CCS Atrial Fibrillation Guidelines Committee has identified a number of areas that require clarification to address commonly asked practical questions related to guidelines application. In the present article a number of such questions are presented and suggestions about how they can be answered are suggested. Among the issues considered are: (1) What duration of AF is clinically significant? (2) How are the risk factors in the CCS Algorithm for selecting anticoagulation therapy derived and defined? (3) How is valvular heart disease defined and how do different forms of valve disease affect the choice of anticoagulant therapy for AF patients? (4) How should we quantify renal dysfunction and how does it affect therapeutic choices? The response to these questions and the underlying logic are provided, along with an indication of future research needed where no specific approach can presently be recommended based on the literature.
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Affiliation(s)
- Laurent Macle
- Montreal Heart Institute and Department of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada
| | - L Brent Mitchell
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Stanley Nattel
- Montreal Heart Institute and Department of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada.
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206
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Arnold J, Sims D, Ferro CJ. Modulation of stroke risk in chronic kidney disease. Clin Kidney J 2015; 9:29-38. [PMID: 26798458 PMCID: PMC4720212 DOI: 10.1093/ckj/sfv136] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/10/2015] [Indexed: 12/12/2022] Open
Abstract
Stroke is the second most common cause of death and the leading cause of neurological disability worldwide, with huge economic costs and tragic human consequences. Both chronic kidney disease (CKD) and end-stage kidney disease are associated with a significantly increased risk of stroke. However, to date this has generated far less interest compared with the better-recognized links between cardiac and renal disease. Common risk factors for stroke, such as hypertension, hypercholesterolaemia, smoking and atrial fibrillation, are shared with the general population but are more prevalent in renal patients. In addition, factors unique to these patients, such as disorders of mineral and bone metabolism, anaemia and its treatments as well as the process of dialysis itself, are all also postulated to further increase the risk of stroke. In the general population, advances in medical therapies mean that effective primary and secondary prevention therapies are available for many patients. The development of specialist stroke clinics and acute stroke units has also improved outcomes after a stroke. Emerging therapies such as thrombolysis and thrombectomy are showing increasingly beneficial results. However, patients with CKD and on dialysis have different risk profiles that must be taken into account when considering the potential benefits and risks of these treatments. Unfortunately, these patients are either not recruited or formally excluded from major clinical trials. There is still much work to be done to harness effective stroke treatments with an acceptable safety profile for patients with CKD and those on dialysis.
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Affiliation(s)
- Julia Arnold
- Department of Nephrology , Queen Elizabeth Hospital , Birmingham , UK
| | - Don Sims
- Department of Stroke Medicine , Queen Elizabeth Hospital , Birmingham , UK
| | - Charles J Ferro
- Department of Nephrology , Queen Elizabeth Hospital , Birmingham , UK
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207
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Shih CJ, Ou SM, Chao PW, Kuo SC, Lee YJ, Yang CY, Tarng DC, Lin CC, Huang PH, Li SY, Chen YT. Risks of Death and Stroke in Patients Undergoing Hemodialysis With New-Onset Atrial Fibrillation: A Competing-Risk Analysis of a Nationwide Cohort. Circulation 2015; 133:265-72. [PMID: 26680239 DOI: 10.1161/circulationaha.115.018294] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 11/11/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Whether oral anticoagulant use should be considered in patients undergoing hemodialysis with atrial fibrillation (AF) remains controversial because of the uncertainty regarding risk-benefit assessments. The purpose of this study was to investigate the risk of ischemic stroke in patients undergoing hemodialysis with new-onset AF, in comparison with those without arrhythmia. METHODS AND RESULTS This nationwide, population-based, propensity score-matched cohort study used data from Taiwan's National Health Insurance Research Database during 1998 to 2011 for patients on hemodialysis with new-onset nonvalvular AF and matched subjects without arrhythmia. The clinical end points were ischemic stroke (fatal or nonfatal), all-cause death, and other serious adverse cardiovascular events. In comparison with the matched cohort, patients with AF (n=6772) had higher risks of ischemic stroke (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [CI], 1.13-1.43), all-cause death (aHR, 1.59; 95% CI, 1.52-1.67), in-hospital cardiovascular death (aHR, 1.83; 95% CI, 1.71-1.94), myocardial infarction (aHR, 1.33; 95% CI, 1.17-1.51), and hospitalization for heart failure (aHR, 1.90; 95% CI, 1.76-2.05). After considering in-hospital death as a competing risk, AF significantly increased the risk of heart failure (HR, 1.56; 95% CI, 1.45-1.68), but not those of ischemic stroke and myocardial infarction. Additionally, the predictive value of the CHA2DS2-VASc score for ischemic stroke was diminished in the competing-risk model. CONCLUSIONS The risk of stroke was only modestly higher in patients undergoing hemodialysis with new-onset AF than in those without AF, and it became insignificant when accounting for the competing risk of in-hospital death.
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Affiliation(s)
- Chia-Jen Shih
- From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.)
| | - Shuo-Ming Ou
- From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.)
| | - Pei-Wen Chao
- From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.)
| | - Shu-Chen Kuo
- From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.)
| | - Yi-Jung Lee
- From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.)
| | - Chih-Yu Yang
- From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.)
| | - Der-Cherng Tarng
- From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.)
| | - Chih-Ching Lin
- From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.)
| | - Po-Hsun Huang
- From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.)
| | - Szu-Yuan Li
- From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.).
| | - Yung-Tai Chen
- From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.).
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Warfarin use and incidence of stroke in Japanese hemodialysis patients with atrial fibrillation. Heart Vessels 2015; 31:1676-80. [DOI: 10.1007/s00380-015-0777-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
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209
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Liu G, Long M, Hu X, Hu CH, Liao XX, Du ZM, Dong YG. Effectiveness and Safety of Warfarin in Dialysis Patients With Atrial Fibrillation: A Meta-Analysis of Observational Studies. Medicine (Baltimore) 2015; 94:e2233. [PMID: 26683937 PMCID: PMC5058909 DOI: 10.1097/md.0000000000002233] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In routine practice, warfarin is widely used in dialysis patients with atrial fibrillation (AF) for stroke prevention though the ratio of risks to benefits remains unclear. Recent cohort studies investigating the association between warfarin use and the risks of stroke and bleeding in dialysis patients with AF present conflicting results. The objective of this study was to assess the effectiveness and safety of warfarin use in patients with AF undergoing dialysis. Three databases PubMed, EMBASE, and OVID were searched from their inception to August 2015. Observational studies which assessed the ischemic stroke or bleeding risk of warfarin use in dialysis patients with AF were included. Two reviewers independently extracted data and assessed methodological quality based on the Newcastle-Ottawa Scale score. Combined hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using the random-effects model and heterogeneity was assessed based on the Cochrane Q-statistic test and the I statistic. Metaregression analyses were performed to explore the source of heterogeneity. A total of 11 eligible studies with 25,407 patients were included in the analysis. Warfarin use, in comparison with no-warfarin use, was not associated with a lower risk for ischemic stroke (HR 0.95, 95% CI 0.66-1.35). Sensitivity analyses found results to be robust. Metaregression analysis showed that demographic feature, clinical characteristics, or study-level variable had no impact of warfarin use on stroke risk. In addition, warfarin use was associated with a 27% higher risk for bleeding (95% CI 1.04-1.54). Overall, warfarin use did not have a significant association with reduced mortality (95% CI 0.96-1.11). It appears that warfarin use is not beneficial in reducing stroke risk, but with a high risk for bleeding in dialysis patients with AF. Randomized trials are needed to determine the risk-benefit ratio of warfarin in dialysis patients with AF.
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Affiliation(s)
- Gang Liu
- From the Department of Cardiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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210
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Safety of warfarin therapy in chronic hemodialysis patients: a prospective cohort study. Clin Exp Nephrol 2015; 20:787-794. [DOI: 10.1007/s10157-015-1205-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
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211
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Chan PH, Siu CW. Clinical Benefit of Warfarin in Dialysis Patients With Atrial Fibrillation. J Am Coll Cardiol 2015; 66:1310-1311. [PMID: 26361166 DOI: 10.1016/j.jacc.2015.03.601] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 03/24/2015] [Indexed: 11/26/2022]
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212
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Mitsuma W, Matsubara T, Hatada K, Imai S, Saito N, Shimada H, Miyazaki S. Clinical characteristics of hemodialysis patients with atrial fibrillation: The RAKUEN (Registry of atrial fibrillation in chronic kidney disease under hemodialysis from Niigata) study. J Cardiol 2015; 68:148-55. [PMID: 26527113 DOI: 10.1016/j.jjcc.2015.08.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/17/2015] [Accepted: 08/27/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Clinical characteristics, management, and outcomes in hemodialysis patients with atrial fibrillation (AF) remain unclear. METHODS AND RESULTS We studied 423 Japanese patients undergoing maintenance hemodialysis (age 65.2±12.4 years, male 70%, mean duration of hemodialysis 139±124 months). AF was present in 19% (n=82) and was independently related to increased age (odds ratio 1.070, 95% confidence interval 1.043-1.098), longer hemodialysis duration (odds ratio 1.006, 95% confidence interval 1.004-1.008), and congestive heart failure (odds ratio 2.749, 95% confidence interval 1.546-4.891). During observations lasting a mean of 36 months, the incidences of all-cause death, cardiovascular death, and major bleeding, in particular gastrointestinal bleeding, were significantly higher in the AF (n=82) than the non-AF (n=341) patients (p<0.001, p=0.004, p=0.002, p=0.027, respectively), but the incidence of ischemic stroke/systemic embolism was similar in the AF and non-AF patients. AF was independently associated with all-cause death (hazard ratio 1.728, 95% confidence interval 1.123-2.660) and major bleeding (hazard ratio 1.984, 95% confidence interval 1.010-3.896). Warfarin was prescribed in 33% of the AF patients, but the rates of all-cause death, ischemic stroke, and major bleeding during the study period were not significantly different between warfarin (n=27) and non-warfarin (n=55) groups. CONCLUSIONS In our hemodialysis patients, AF was a common comorbidity and was independently associated with all-cause death and major bleeding, but not with increased risk of ischemic stroke.
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Affiliation(s)
- Wataru Mitsuma
- Division of Cardiology, Shinrakuen Hospital, Niigata, Japan.
| | - Taku Matsubara
- Division of Cardiology, Shinrakuen Hospital, Niigata, Japan
| | | | - Shunsuke Imai
- Division of Cardiology, Shinrakuen Hospital, Niigata, Japan
| | - Noriko Saito
- Division of Nephrology, Shinrakuen Hospital, Niigata, Japan
| | - Hisaki Shimada
- Division of Nephrology, Shinrakuen Hospital, Niigata, Japan
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213
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Chan PH, Huang D, Yip PS, Hai J, Tse HF, Chan TM, Lip GY, Lo WK, Siu CW. Ischaemic stroke in patients with atrial fibrillation with chronic kidney disease undergoing peritoneal dialysis. Europace 2015; 18:665-71. [DOI: 10.1093/europace/euv289] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 08/03/2015] [Indexed: 01/04/2023] Open
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214
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Mittal M, Aggarwal K, Littrell RL, Agrawal H, Alpert MA. Does pharmacotherapy improve cardiovascular outcomes in hemodialysis patients? Hemodial Int 2015; 19 Suppl 3:S40-50. [DOI: 10.1111/hdi.12352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mayank Mittal
- Division of Cardiovascular Medicine; University of Missouri School of Medicine; Columbia Missouri USA
| | - Kul Aggarwal
- Division of Cardiovascular Medicine; University of Missouri School of Medicine; Columbia Missouri USA
| | - Rachel L. Littrell
- Division of Cardiovascular Medicine; University of Missouri School of Medicine; Columbia Missouri USA
| | - Harsh Agrawal
- Division of Cardiovascular Medicine; University of Missouri School of Medicine; Columbia Missouri USA
| | - Martin A. Alpert
- Division of Cardiovascular Medicine; University of Missouri School of Medicine; Columbia Missouri USA
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Shah M, Avgil Tsadok M, Jackevicius CA, Essebag V, Eisenberg MJ, Rahme E, Humphries KH, Tu JV, Behlouli H, Guo H, Pilote L. Response to letter regarding article, "Warfarin use and the risk for stroke and bleeding in patients with atrial fibrillation undergoing dialysis". Circulation 2015; 130:e428-9. [PMID: 25539527 DOI: 10.1161/circulationaha.114.012785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Mitesh Shah
- Divisions of Clinical Epidemiology and General Internal Medicine, McGill University Health Center, Montreal, QC, Canada
| | - Meytal Avgil Tsadok
- Divisions of Clinical Epidemiology and General Internal Medicine, McGill University Health Center, Montreal, QC, Canada
| | - Cynthia A Jackevicius
- Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, California, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada, University Health Network, Toronto, ON, Canada
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, Montreal, QC, Canada
| | - Mark J Eisenberg
- Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital/McGill University, Montreal, QC, Canada
| | - Elham Rahme
- Divisions of Clinical Epidemiology and General Internal Medicine, McGill University Health Center, Montreal, QC, Canada
| | - Karin H Humphries
- Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | - Jack V Tu
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada, Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada, Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Hassan Behlouli
- Divisions of Clinical Epidemiology and General Internal Medicine, McGill University Health Center, Montreal, QC, Canada
| | - Helen Guo
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Louise Pilote
- Divisions of Clinical Epidemiology and General Internal Medicine, McGill University Health Center, Montreal, QC, Canada
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216
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Comparison of novel oral anticoagulants versus vitamin K antagonists in patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2015; 24:183-92. [PMID: 25636144 DOI: 10.1097/mnh.0000000000000098] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Novel oral anticoagulants (NOACs) including apixaban, dabigatran and rivaroxaban have been approved by international regulatory agencies to prevent venous thromboembolism as well as treat atrial fibrillation and venous thromboembolism in individuals with chronic kidney disease (CKD). However, alterations in their metabolism in the setting of CKD may impact their efficacy and lead to an increased risk of bleeding. This review summarizes the current literature on the efficacy and safety of these agents in individuals with moderate CKD. RECENT FINDINGS In clinical trials, the use of the NOACs in patients with moderate CKD has demonstrated efficacy and safety similar to those seen with vitamin K antagonists. However, no universal reversal agent for the anticoagulant effect of the NOACs exists in the setting of bleeding. Limited data have demonstrated that hemodialysis has been effectively used to aid in reversing the effects of dabigatran, and the use of prothrombin complex concentrate has also been used for serious and major adverse bleeding events with some success. SUMMARY As the use of the NOACs in patients with CKD increases, it will be important to monitor their safety, and clinicians who prescribe them should carefully monitor kidney function and recognize the potential for adverse effects.
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217
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Barrios V, Górriz JL. Atrial fibrillation and chronic kidney disease: focus on rivaroxaban. J Comp Eff Res 2015; 4:651-64. [PMID: 26388302 DOI: 10.2217/cer.15.44] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Renal insufficiency increases the risk of stroke and bleeding in atrial fibrillation patients. Although vitamin K antagonists reduce the risk of stroke in patients with moderate renal dysfunction, this observation is less clear in patients with renal impairment. Moreover, the risk of bleeding with vitamin K antagonists increases as renal function worsens. Maintaining international normalized ratio values within therapeutic targets is more difficult in patients with renal dysfunction, and those agents may cause warfarin-related nephropathy and vascular calcification. Rivaroxaban is the only nonvitamin K oral anticoagulant with a dose specifically tested in patients with moderate renal insufficiency. Rivaroxaban is effective for the prevention of stroke in atrial fibrillation patients with moderate renal dysfunction, with a lower risk of intracranial and fatal bleeding.
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Affiliation(s)
- Vivencio Barrios
- Department of Cardiology, University Hospital Ramón y Cajal, School of Medicine, Alcalá University, Madrid, Spain
| | - José Luis Górriz
- Department of Nephrology, Doctor Peset University Hospital, Department of Medicine, University of Valencia, Valencia, Spain
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218
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Bonde AN, Kamper AL, Olesen JB. Reply. J Am Coll Cardiol 2015; 66:1311. [DOI: 10.1016/j.jacc.2015.05.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 05/21/2015] [Accepted: 05/26/2015] [Indexed: 10/23/2022]
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219
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Findlay MD, Thomson PC, Fulton RL, Solbu MD, Jardine AG, Patel RK, Stevens KK, Geddes CC, Dawson J, Mark PB. Risk Factors of Ischemic Stroke and Subsequent Outcome in Patients Receiving Hemodialysis. Stroke 2015; 46:2477-81. [DOI: 10.1161/strokeaha.115.009095] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 06/23/2015] [Indexed: 12/23/2022]
Abstract
Background and Purpose—
End-stage renal disease (ESRD) requiring hemodialysis carries up to a 10-fold greater risk of stroke than normal renal function. Knowledge on risk factors and management strategies derived from the general population may not be applicable to those with ESRD. We studied a large ESRD population to identify risk factors and outcomes for stroke.
Methods—
All adult patients receiving hemodialysis for ESRD from January 1, 2007, to December 31, 2012, were extracted from the electronic patient record. Variables associated with stroke were identified by survival analysis; demographic, clinical, imaging, and dialysis-related variables were assessed, and case-fatality was determined. Follow-up was until December 31, 2013.
Results—
A total of 1382 patients were identified (mean age, 60.5 years; 58.5% men). The prevalence of atrial fibrillation was 21.2%, and 59.4% were incident hemodialysis patients. One hundred and sixty patients (11.6%) experienced a stroke during 3471 patient-years of follow-up (95% ischemic). Stroke incidence was 41.5/1000 patient-years in prevalent and 50.1/1000 patient-years in incident hemodialysis patients. Factors associated with stroke on regression analysis were prior stroke, diabetes mellitus, and age at starting renal replacement therapy. Atrial fibrillation was not significantly associated with stroke, and warfarin did not affect stroke risk in warfarin-treated patients. Fatality was 18.8% at 7 days, 26.9% at 28 days, and 56.3% at 365 days after stroke.
Conclusions—
Incidence of stroke is high in patients with ESRD on hemodialysis with high case-fatality. Incident hemodialysis patients had the highest stroke incidence. Many, but not all, important risk factors commonly associated with stroke in the general population were not associated with stroke in patients receiving hemodialysis.
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Affiliation(s)
- Mark D. Findlay
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (M.D.F., R.L.F., M.D.S., A.G.J., R.K.P., K.K.S., J.D., P.B.M.); and The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, United Kingdom (M.D.F., P.C.T., M.D.S., A.G.J., R.K.P., K.K.S., C.C.G., P.B.M.)
| | - Peter C. Thomson
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (M.D.F., R.L.F., M.D.S., A.G.J., R.K.P., K.K.S., J.D., P.B.M.); and The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, United Kingdom (M.D.F., P.C.T., M.D.S., A.G.J., R.K.P., K.K.S., C.C.G., P.B.M.)
| | - Rachael L. Fulton
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (M.D.F., R.L.F., M.D.S., A.G.J., R.K.P., K.K.S., J.D., P.B.M.); and The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, United Kingdom (M.D.F., P.C.T., M.D.S., A.G.J., R.K.P., K.K.S., C.C.G., P.B.M.)
| | - Marit D. Solbu
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (M.D.F., R.L.F., M.D.S., A.G.J., R.K.P., K.K.S., J.D., P.B.M.); and The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, United Kingdom (M.D.F., P.C.T., M.D.S., A.G.J., R.K.P., K.K.S., C.C.G., P.B.M.)
| | - Alan G. Jardine
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (M.D.F., R.L.F., M.D.S., A.G.J., R.K.P., K.K.S., J.D., P.B.M.); and The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, United Kingdom (M.D.F., P.C.T., M.D.S., A.G.J., R.K.P., K.K.S., C.C.G., P.B.M.)
| | - Rajan K. Patel
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (M.D.F., R.L.F., M.D.S., A.G.J., R.K.P., K.K.S., J.D., P.B.M.); and The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, United Kingdom (M.D.F., P.C.T., M.D.S., A.G.J., R.K.P., K.K.S., C.C.G., P.B.M.)
| | - Kathryn K. Stevens
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (M.D.F., R.L.F., M.D.S., A.G.J., R.K.P., K.K.S., J.D., P.B.M.); and The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, United Kingdom (M.D.F., P.C.T., M.D.S., A.G.J., R.K.P., K.K.S., C.C.G., P.B.M.)
| | - Colin C. Geddes
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (M.D.F., R.L.F., M.D.S., A.G.J., R.K.P., K.K.S., J.D., P.B.M.); and The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, United Kingdom (M.D.F., P.C.T., M.D.S., A.G.J., R.K.P., K.K.S., C.C.G., P.B.M.)
| | - Jesse Dawson
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (M.D.F., R.L.F., M.D.S., A.G.J., R.K.P., K.K.S., J.D., P.B.M.); and The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, United Kingdom (M.D.F., P.C.T., M.D.S., A.G.J., R.K.P., K.K.S., C.C.G., P.B.M.)
| | - Patrick B. Mark
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (M.D.F., R.L.F., M.D.S., A.G.J., R.K.P., K.K.S., J.D., P.B.M.); and The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, United Kingdom (M.D.F., P.C.T., M.D.S., A.G.J., R.K.P., K.K.S., C.C.G., P.B.M.)
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Li J, Wang L, Hu J, Xu G. Warfarin use and the risks of stroke and bleeding in hemodialysis patients with atrial fibrillation: A systematic review and a meta-analysis. Nutr Metab Cardiovasc Dis 2015; 25:706-713. [PMID: 26026205 DOI: 10.1016/j.numecd.2015.03.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 03/13/2015] [Accepted: 03/23/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIM The efficacy and safety of warfarin therapy in hemodialysis (HD) patients with atrial fibrillation (AF) remains controversial. Thus, we performed, up to date, the first meta-analysis on the risks of stroke and bleeding in warfarin treatment in these populations. METHODS AND RESULTS The relevant literature was searched using the following electronic databases without any language restrictions: the Cochrane Library Database, PubMed, ISI, Ovid, and Chinese Biomedical Database from the establishment of the database to October 2014. The studies were included if (a) studies described the risk of stroke or bleeding with or without warfarin in dialysis patients with AF, (b) studies provided information about hazard ratio (HR) and 95% confidence interval (CI) of stroke or bleeding, and (c) the study design was a clinical cohort. The inverse variance method was used to obtain overall HRs and 95% CIs. Sensitivity analyses and publication bias were also performed. We identified six eligible studies with a total of 9816 patients. Combined HRs showed that warfarin cannot prevent strokes in HD patients with AF (HR = 1.23, 95% CI 0.80-1.87; P = 0.347), but its use was associated with a higher risk of bleeding (HR = 1.20, 95% CI 1.03-1.39; P = 0.019). CONCLUSION This meta-analysis suggested that warfarin should not be recommended for the routine treatment of HD patients with AF.
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Affiliation(s)
- Jingzhen Li
- Medical Center of the Graduate School, Nanchang University, Nanchang, PR China
| | - Lijuan Wang
- Medical Center of the Graduate School, Nanchang University, Nanchang, PR China
| | - Jinzhu Hu
- Department of Cardiology, Second Affiliated Hospital, Nanchang University, Nanchang, PR China
| | - Gaosi Xu
- Department of Nephrology, Second Affiliated Hospital, Nanchang University, No. 1, Minde Road, Nanchang 330006, PR China.
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221
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Qamar A, Bhatt DL. Warfarin in patients on haemodialysis with atrial fibrillation—friend or foe? Nat Rev Nephrol 2015; 11:450. [DOI: 10.1038/nrneph.2015.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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222
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Boriani G, Savelieva I, Dan GA, Deharo JC, Ferro C, Israel CW, Lane DA, La Manna G, Morton J, Mitjans AM, Vos MA, Turakhia MP, Lip GY. Chronic kidney disease in patients with cardiac rhythm disturbances or implantable electrical devices: clinical significance and implications for decision making-a position paper of the European Heart Rhythm Association endorsed by the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society. Europace 2015; 17:1169-96. [PMID: 26108808 PMCID: PMC6281310 DOI: 10.1093/europace/euv202] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Giuseppe Boriani
- Corresponding author. Giuseppe Boriani, Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S.Orsola-Malpighi University Hospital, Via Massarenti 9, 40138 Bologna, Italy. Tel: +39 051 349858; fax: +39 051 344859. E-mail address:
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223
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Schlieper G, Floege J. Challenging the use of warfarin in patients on dialysis with atrial fibrillation. Nat Rev Nephrol 2015; 11:450. [PMID: 26149840 DOI: 10.1038/nrneph.2015.87] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Georg Schlieper
- Divisions of Nephrology and Immunology, Uniklinik RWTH University of Aachen, Pauwelstrasse 30, D-52057 Aachen, Germany
| | - Jürgen Floege
- Divisions of Nephrology and Immunology, Uniklinik RWTH University of Aachen, Pauwelstrasse 30, D-52057 Aachen, Germany
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224
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Shen JI, Montez-Rath ME, Lenihan CR, Turakhia MP, Chang TI, Winkelmayer WC. Outcomes After Warfarin Initiation in a Cohort of Hemodialysis Patients With Newly Diagnosed Atrial Fibrillation. Am J Kidney Dis 2015; 66:677-88. [PMID: 26162653 DOI: 10.1053/j.ajkd.2015.05.019] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 05/15/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although warfarin is indicated to prevent ischemic strokes in most patients with atrial fibrillation (AF), evidence supporting its use in hemodialysis patients is limited. Our aim was to examine outcomes after warfarin therapy initiation, relative to no warfarin use, following incident AF in a large cohort of hemodialysis patients who had comprehensive prescription drug coverage through Medicare Part D. STUDY DESIGN Retrospective observational cohort study. SETTING & PARTICIPANTS Patients in the US Renal Data System undergoing maintenance hemodialysis who had AF newly diagnosed in 2007 to 2011, with Medicare Part D coverage, who had no recorded history of warfarin use. PREDICTOR Warfarin therapy initiation, identified by a filled prescription within 30 days of the AF event. OUTCOMES Death, ischemic stroke, hemorrhagic stroke, severe gastrointestinal bleeding, and composite outcomes. MEASUREMENTS HRs estimated by applying Cox regression to an inverse probability of treatment and censoring-weighted cohort. RESULTS Of 12,284 patients with newly diagnosed AF, 1,838 (15%) initiated warfarin therapy within 30 days; however, ∼70% discontinued its use within 1 year. In intention-to-treat analyses, warfarin use was marginally associated with a reduced risk of ischemic stroke (HR, 0.68; 95% CI, 0.47-0.99), but not with the other outcomes. In as-treated analyses, warfarin use was associated with reduced mortality (HR, 0.84; 95% CI, 0.73-0.97). LIMITATIONS Short observation period, limited number of nonfatal events, limited generalizability of results to more affluent patients. CONCLUSIONS In hemodialysis patients with incident AF, warfarin use was marginally associated with reduced risk of ischemic stroke, and there was a signal toward reduced mortality in as-treated analyses. These results support clinical equipoise regarding the use of warfarin in hemodialysis patients and underscore the need for randomized trials to fill this evidence gap.
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Affiliation(s)
- Jenny I Shen
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Colin R Lenihan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Mintu P Turakhia
- Division of Cardiovascular Medicine, Department of Medicine, Palo Alto, CA; Veterans Affairs Palo Alto Health Care System, Stanford University School of Medicine, Palo Alto, CA
| | - Tara I Chang
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Wolfgang C Winkelmayer
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; Division of Cardiovascular Medicine, Department of Medicine, Palo Alto, CA.
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225
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Chao TF, Chen SA. Risk of Ischemic Stroke and Stroke Prevention in Patients with Atrial Fibrillation and Renal Dysfunction. J Atr Fibrillation 2015; 8:1196. [PMID: 27957171 DOI: 10.4022/jafib.1196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 05/07/2015] [Accepted: 06/25/2015] [Indexed: 12/31/2022]
Abstract
Chronic kidney disease (CKD) has been identified as an important risk factor for new-onset atrial fibrillation (AF) and would significantly increase the risk of AF-related strokes. Stroke prevention in AF patients with CKD is a big challenge, especially for patients with end-stage renal disease (ESRD) undergoing long-term dialysis. In addition to an increase risk of stroke, renal dysfunction was also associated with a higher risk of hemorrhage due to dysregulation of coagulation and uremia-mediated platelet dysfunction. Therefore, the net clinical benefit balancing stroke risk reduction and increased risk of bleeding should be weighed carefully before initiating oral anti-coagulants for ESRD patients. Several studies investigating whether warfarin should be used for stroke prevention in AF patients with ESRD have been published and showed inconsistent results. Since none of these studies was a prospective and randomized trial, the best strategy for stroke prevention in AF patients with ESRD undergoing dialysis remained unknown and more data are necessary to answer this issue.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
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Abstract
In the setting of end-stage kidney disease, the incidence and risk for thrombotic events are increased and use of anticoagulants is common. The incidence of bleeding, however, is also a frequent issue and creates additional challenges in the management of anticoagulation therapy. Patients with end-stage renal disease are typically excluded from large clinical trials exploring the use of anticoagulants, which limits our knowledge of optimal management approaches. Furthermore, varying degrees of renal failure in addition to conditions that alter the pharmacokinetics of various anticoagulants or pharmacodynamic response may warrant alternative approaches to dosing. This review will explore systemic chronic anticoagulation therapy in the setting of chronic kidney disease where hemodialysis is required. Agents discussed include vitamin K antagonists, low-molecular-weight heparins, fondaparinux, oral factor Xa antagonists, and direct thrombin inhibitors. Clinical challenges, approaches to dosing regimens, and tools for measuring responses and reversal will be explored.
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Affiliation(s)
- William E Dager
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California.,Departments of Medicine and Pharmaceutical Services, Davis Medical Center, University of California Davis School of Medicine, Sacramento, California.,Department of Pharmacy, Touro Vallejo School of Pharmacy, Vallejo, California
| | - Laura V Tsu
- Department of Pharmacy Practice, Midwestern College of Pharmacy, Glendale, Arizona
| | - Tiffany K Pon
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, San Francisco, California
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228
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Schlieper G, Hess K, Floege J, Marx N. The vulnerable patient with chronic kidney disease. Nephrol Dial Transplant 2015; 31:382-90. [DOI: 10.1093/ndt/gfv041] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 01/25/2015] [Indexed: 11/14/2022] Open
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229
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Galloway PA, El-Damanawi R, Bardsley V, Pritchard NR, Fry AC, Ojha SK, Hiemstra TF. Vitamin K Antagonists Predispose to Calciphylaxis in Patients with End-Stage Renal Disease. Nephron Clin Pract 2015; 129:197-201. [DOI: 10.1159/000371449] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 12/09/2014] [Indexed: 11/19/2022] Open
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Jun M, James MT, Manns BJ, Quinn RR, Ravani P, Tonelli M, Perkovic V, Winkelmayer WC, Ma Z, Hemmelgarn BR. The association between kidney function and major bleeding in older adults with atrial fibrillation starting warfarin treatment: population based observational study. BMJ 2015; 350:h246. [PMID: 25647223 PMCID: PMC6169066 DOI: 10.1136/bmj.h246] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2014] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To determine rates of major bleeding by level of kidney function for older adults with atrial fibrillation starting warfarin. DESIGN Retrospective cohort study. SETTING Community based, using province wide laboratory and administrative data in Alberta, Canada. PARTICIPANTS 12,403 adults aged 66 years or more, with atrial fibrillation who started warfarin treatment between 1 May 2003 and 31 March 2010 and had a measure of kidney function at baseline. Kidney function was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation and participants were categorised based on estimated glomerular filtration rate (eGFR): ≥ 90, 60-89, 45-59, 30-44, 15-29, <15 mL/min/1.73 m(2). We excluded participants with end stage renal disease (dialysis or renal transplant) at baseline. MAIN OUTCOME MEASURES Admission to hospital or visit to an emergency department for major bleeding (intracranial, upper and lower gastrointestinal, or other). RESULTS Of 12,403 participants, 45% had an eGFR <60 mL/min/1.73 m(2). Overall, 1443 (11.6%) experienced a major bleeding episode over a median follow-up of 2.1 (interquartile range: 1.0-3.8) years. During the first 30 days of warfarin treatment, unadjusted and adjusted rates of major bleeding were higher at lower eGFR (P for trend <0.001 and 0.001, respectively). Adjusted bleeding rates per 100 person years were 63.4 (95% confidence interval 24.9 to 161.6) in participants with eGFR <15 mL/min/1.73 m(2) compared with 6.1 (1.9 to 19.4) among those with eGFR >90 mL/min/1.73 m(2) (adjusted incidence rate ratio 10.3, 95% confidence interval 2.3 to 45.5). Similar associations were observed at more than 30 days after starting warfarin, although the magnitude of the increase in rates across eGFR categories was attenuated. Across all eGFR categories, adjusted rates of major bleeding were consistently higher during the first 30 days of warfarin treatment compared with the remainder of follow-up. Increases in major bleeding rates were largely due to gastrointestinal bleeding (3.5-fold greater in eGFR <15 mL/min/1.73 m(2) compared with ≥ 90 mL/min/1.73 m(2)). Intracranial bleeding was not increased with worsening kidney function. CONCLUSIONS Reduced kidney function was associated with an increased risk of major bleeding among older adults with atrial fibrillation starting warfarin; excess risks from reduced eGFR were most pronounced during the first 30 days of treatment. Our results support the need for careful consideration of the bleeding risk relative to kidney function when assessing the risk-benefit ratio of warfarin treatment in people with chronic kidney disease and atrial fibrillation, particularly in the first 30 days of treatment.
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Affiliation(s)
- Min Jun
- Department of Medicine, Division of Nephrology, University of Calgary, AB, Canada, T2N 2T9
| | - Matthew T James
- Department of Medicine, Division of Nephrology, University of Calgary, AB, Canada, T2N 2T9 Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Braden J Manns
- Department of Medicine, Division of Nephrology, University of Calgary, AB, Canada, T2N 2T9 Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Robert R Quinn
- Department of Medicine, Division of Nephrology, University of Calgary, AB, Canada, T2N 2T9 Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Pietro Ravani
- Department of Medicine, Division of Nephrology, University of Calgary, AB, Canada, T2N 2T9 Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Marcello Tonelli
- Department of Medicine, Division of Nephrology, University of Calgary, AB, Canada, T2N 2T9
| | - Vlado Perkovic
- The George Institute for Global Health, The University of Sydney, Sydney, Australia
| | | | - Zhihai Ma
- Department of Medicine, Division of Nephrology, University of Calgary, AB, Canada, T2N 2T9
| | - Brenda R Hemmelgarn
- Department of Medicine, Division of Nephrology, University of Calgary, AB, Canada, T2N 2T9 Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Szummer K, Carrero JJ. Warfarin therapy for atrial fibrillation in haemodialysis patients: mind the (evidence) gap. Nephrol Dial Transplant 2015; 30:337-9. [PMID: 25618888 DOI: 10.1093/ndt/gfu412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Karolina Szummer
- Department of Medicine, Division of Cardiology, Karolinska Institutet, Stockholm, Sweden
| | - Juan Jesús Carrero
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine and Baxter Novum, Karolinska Institutet, Stockholm, Sweden Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
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233
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Qureshi W, Alirhayim Z, Khalid F. Letter by Qureshi et al regarding article, "Warfarin use and the risk for stroke and bleeding in patients with atrial fibrillation undergoing dialysis". Circulation 2014; 130:e427. [PMID: 25539526 DOI: 10.1161/circulationaha.114.010090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Waqas Qureshi
- Division of Cardiology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston Salem, NC
| | - Zaid Alirhayim
- Division of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, KS
| | - Fatima Khalid
- Division of Nephrology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston Salem, NC
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Abstract
Abstract
More than 4 years have passed since the first approval of a target-specific oral anticoagulant (TSOAC) in the United States, and the number of clinicians who have prescribed (or considered prescribing) one or more of these medications is increasing. Although these agents may, in properly selected patients, offer advantages over more traditional therapies, their lack of familiarity can be intimidating. Clinicians who are prescribing the TSOACs face a number of management questions not definitively answered by the registration trials. This chapter reviews some of these situations, including updated information on the periprocedural management of TSOACs and the latest evidence about how to best measure TSOAC effect. The lack of an antidote and other considerations that may be relevant when deciding between newer and more traditional anticoagulant medications are also discussed.
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235
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Chen JJ, Lin LY, Yang YH, Hwang JJ, Chen PC, Lin JL. Anti-platelet or anti-coagulant agent for the prevention of ischemic stroke in patients with end-stage renal disease and atrial fibrillation—A nation-wide database analyses. Int J Cardiol 2014; 177:1008-11. [DOI: 10.1016/j.ijcard.2014.09.140] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 09/15/2014] [Accepted: 09/27/2014] [Indexed: 11/30/2022]
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236
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Bonde AN, Lip GY, Kamper AL, Hansen PR, Lamberts M, Hommel K, Hansen ML, Gislason GH, Torp-Pedersen C, Olesen JB. Net Clinical Benefit of Antithrombotic Therapy in Patients With Atrial Fibrillation and Chronic Kidney Disease. J Am Coll Cardiol 2014; 64:2471-82. [DOI: 10.1016/j.jacc.2014.09.051] [Citation(s) in RCA: 216] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 08/19/2014] [Accepted: 09/16/2014] [Indexed: 11/26/2022]
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237
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Baber U, Mastoris I, Mehran R. Balancing ischaemia and bleeding risks with novel oral anticoagulants. Nat Rev Cardiol 2014; 11:693-703. [PMID: 25367652 DOI: 10.1038/nrcardio.2014.170] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Vitamin K antagonists (VKAs) have long been the standard of care for treatment of venous thromboembolism (VTE), and thromboprophylaxis in atrial fibrillation (AF). Despite their efficacy, their use requires frequent monitoring and is complicated by drug-drug interactions and the need to maintain a narrow therapeutic window. Since 2009, novel oral anticoagulants (NOACs), including the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors apixaban, edoxaban, and rivaroxaban, have become alternative options to VKAs owing to their predictable and safe pharmacological profiles. The overall clinical effect of these drugs, which is a balance between ischaemic benefit and bleeding harm, varies according to the clinical scenario. As adjunctive therapy to dual antiplatelet therapy in patients with acute coronary syndrome, NOACs are associated with incremental bleeding risks and modest benefits. For treatment of VTE, NOACs have a safer profile than VKAs and a similar efficacy. In thromboprophylaxis in AF, NOACs are associated with the greatest benefits by reducing both ischaemic events and haemorrhagic complications and might reduce mortality compared with VKAs. The role of NOACs continues to evolve as these drugs are evaluated in different patient populations, including those with renal impairment or with AF and undergoing percutaneous coronary intervention.
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Affiliation(s)
- Usman Baber
- Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, PO Box 1030, New York, NY 10029, USA
| | - Ioannis Mastoris
- Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, PO Box 1030, New York, NY 10029, USA
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, PO Box 1030, New York, NY 10029, USA
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238
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El Husseini N, Kaskar O, Goldstein LB. Chronic kidney disease and stroke. Adv Chronic Kidney Dis 2014; 21:500-8. [PMID: 25443575 DOI: 10.1053/j.ackd.2014.09.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 09/05/2014] [Accepted: 09/05/2014] [Indexed: 12/19/2022]
Abstract
Chronic kidney disease (CKD) is associated with an increased risk of both ischemic and hemorrhagic stroke. In addition to shared risk factors, this higher cerebrovascular risk is mediated by several CKD-associated mechanisms including platelet dysfunction, coagulation disorders, endothelial dysfunction, inflammation, and increased risk of atrial fibrillation. CKD can also modify the effect of treatments used in acute stroke and in secondary stroke prevention. We review the epidemiology and pathophysiology that link CKD and stroke and the impact of CKD on stroke outcomes. Interdisciplinary collaboration between nephrologists, pharmacists, hematologists, nutrition therapists, primary care physicians, and neurologists in providing care to these subjects may potentially improve outcomes.
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239
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Bansal N. The debate on warfarin use in dialysis patients with atrial fibrillation: more fuel for the fire. Am J Kidney Dis 2014; 64:677-80. [PMID: 24833202 PMCID: PMC4209313 DOI: 10.1053/j.ajkd.2014.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 04/22/2014] [Indexed: 11/11/2022]
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240
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Genovesi S, Rossi E, Gallieni M, Stella A, Badiali F, Conte F, Pasquali S, Bertoli S, Ondei P, Bonforte G, Pozzi C, Rebora P, Valsecchi MG, Santoro A. Warfarin use, mortality, bleeding and stroke in haemodialysis patients with atrial fibrillation. Nephrol Dial Transplant 2014; 30:491-8. [DOI: 10.1093/ndt/gfu334] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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241
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Lenihan CR, Montez-Rath ME, Shen JI, Scandling JD, Turakhia MP, Chang TI, Winkelmayer WC. Correlates and outcomes of warfarin initiation in kidney transplant recipients newly diagnosed with atrial fibrillation. Nephrol Dial Transplant 2014; 30:321-9. [PMID: 25335507 DOI: 10.1093/ndt/gfu323] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In the kidney transplant population with atrial fibrillation (AF), evidence regarding the effectiveness and safety of warfarin treatment is lacking. We used fee-for-service Medicare claims to identify kidney transplant recipients with newly diagnosed AF from the United States Renal Data System. Warfarin use within 30 days of AF diagnosis was ascertained from Medicare Part D prescription claims (2007-11) or using a validated algorithm (1997-2011). The study end points were (i) the composite of death, stroke or gastrointestinal bleed, (ii) death and (iii) death-censored graft failure. Warfarin user and non-user groups were balanced using inverse probability of treatment weighting and hazard ratios were (HRs) estimated using Cox regression. Among 718 subjects with an indication for anticoagulation, 24% initiated warfarin treatment within 30 days of AF diagnosis. Age was the only independent correlate of warfarin use [odds ratio = 1.02 per year; 95% confidence interval (95% CI) 1.01-1.04]. In the larger cohort of 6492 patients with AF, warfarin use [(23.5%) versus non-use (76.5%)] was associated with small and non-significant reductions in the composite of death, stroke or gastrointestinal bleed (HR = 0.92; 95% CI 0.83-1.02), death (HR = 0.92; 95% CI 0.82-1.02) and death-censored graft failure (HR = 0.90; 95% CI 0.76-1.08). Our study suggests the need for clinical trials of warfarin use in the kidney transplant population with AF.
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Affiliation(s)
- Colin R Lenihan
- Divisions of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Maria E Montez-Rath
- Divisions of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jenny I Shen
- Divisions of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - John D Scandling
- Divisions of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mintu P Turakhia
- Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Tara I Chang
- Divisions of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Wolfgang C Winkelmayer
- Divisions of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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242
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Alshogran OY, Naud J, Ocque AJ, Leblond FA, Pichette V, Nolin TD. Effect of experimental kidney disease on the functional expression of hepatic reductases. Drug Metab Dispos 2014; 43:100-6. [PMID: 25332430 DOI: 10.1124/dmd.114.061150] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Chronic kidney disease (CKD) affects the nonrenal clearance of drugs by modulating the functional expression of hepatic drug-metabolizing enzymes and transporters. The impact of CKD on oxidative and conjugative metabolism has been extensively studied. However, its effect on hepatic drug reduction, an important phase I drug-metabolism pathway, has not been investigated. We aimed to assess the effect of experimental CKD on hepatic reduction using warfarin as a pharmacological probe substrate. Cytosolic and microsomal cellular fractions were isolated from liver tissue harvested from five-sixths-nephrectomized and control rats (n = 10 per group). The enzyme kinetics for warfarin reduction were evaluated in both fractions, and formation of warfarin alcohols was used as an indicator of hepatic reductase activity. Selective inhibitors were employed to identify reductases involved in warfarin reduction. Gene and protein expression of reductases were determined using quantitative real-time polymerase chain reaction and Western blotting, respectively. Formation of RS/SR-warfarin alcohol was decreased by 39% (P < 0.001) and 43% (P < 0.01) in cytosol and microsomes, respectively, in CKD rats versus controls. However, RR/SS-warfarin alcohol formation was unchanged in the cytosol, and a trend toward its decreased production was observed in microsomes. Gene and protein expression of cytosolic carbonyl reductase 1 and aldo-keto reductase 1C3/18, and microsomal 11β-hydroxysteroid dehydrogenase type 1 were significantly reduced by >30% (P < 0.05) in CKD rats compared with controls. Collectively, these results suggest that the functional expression of hepatic reductases is selectively decreased in kidney disease. Our findings may explain one mechanism for altered nonrenal clearance, exposure, and response of drugs in CKD patients.
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Affiliation(s)
- Osama Y Alshogran
- Center for Clinical Pharmaceutical Sciences (O.Y.A., A.J.O., T.D.N.), Department of Pharmaceutical Sciences (O.Y.A.) and Department of Pharmacy and Therapeutics (T.D.N.), School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania; and Service de Néphrologie et Centre de Recherche, Hôpital Maisonneuve-Rosemont (J.N., F.A.L., V.P.), Département de Pharmacologie (V.P.), Université de Montréal, Montréal, Québec, Canada
| | - Judith Naud
- Center for Clinical Pharmaceutical Sciences (O.Y.A., A.J.O., T.D.N.), Department of Pharmaceutical Sciences (O.Y.A.) and Department of Pharmacy and Therapeutics (T.D.N.), School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania; and Service de Néphrologie et Centre de Recherche, Hôpital Maisonneuve-Rosemont (J.N., F.A.L., V.P.), Département de Pharmacologie (V.P.), Université de Montréal, Montréal, Québec, Canada
| | - Andrew J Ocque
- Center for Clinical Pharmaceutical Sciences (O.Y.A., A.J.O., T.D.N.), Department of Pharmaceutical Sciences (O.Y.A.) and Department of Pharmacy and Therapeutics (T.D.N.), School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania; and Service de Néphrologie et Centre de Recherche, Hôpital Maisonneuve-Rosemont (J.N., F.A.L., V.P.), Département de Pharmacologie (V.P.), Université de Montréal, Montréal, Québec, Canada
| | - François A Leblond
- Center for Clinical Pharmaceutical Sciences (O.Y.A., A.J.O., T.D.N.), Department of Pharmaceutical Sciences (O.Y.A.) and Department of Pharmacy and Therapeutics (T.D.N.), School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania; and Service de Néphrologie et Centre de Recherche, Hôpital Maisonneuve-Rosemont (J.N., F.A.L., V.P.), Département de Pharmacologie (V.P.), Université de Montréal, Montréal, Québec, Canada
| | - Vincent Pichette
- Center for Clinical Pharmaceutical Sciences (O.Y.A., A.J.O., T.D.N.), Department of Pharmaceutical Sciences (O.Y.A.) and Department of Pharmacy and Therapeutics (T.D.N.), School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania; and Service de Néphrologie et Centre de Recherche, Hôpital Maisonneuve-Rosemont (J.N., F.A.L., V.P.), Département de Pharmacologie (V.P.), Université de Montréal, Montréal, Québec, Canada
| | - Thomas D Nolin
- Center for Clinical Pharmaceutical Sciences (O.Y.A., A.J.O., T.D.N.), Department of Pharmaceutical Sciences (O.Y.A.) and Department of Pharmacy and Therapeutics (T.D.N.), School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania; and Service de Néphrologie et Centre de Recherche, Hôpital Maisonneuve-Rosemont (J.N., F.A.L., V.P.), Département de Pharmacologie (V.P.), Université de Montréal, Montréal, Québec, Canada
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Frendl G, Sodickson AC, Chung MK, Waldo AL, Gersh BJ, Tisdale JE, Calkins H, Aranki S, Kaneko T, Cassivi S, Smith SC, Darbar D, Wee JO, Waddell TK, Amar D, Adler D. 2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. J Thorac Cardiovasc Surg 2014; 148:e153-93. [PMID: 25129609 PMCID: PMC4454633 DOI: 10.1016/j.jtcvs.2014.06.036] [Citation(s) in RCA: 178] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 02/06/2023]
Affiliation(s)
- Gyorgy Frendl
- Department of Anesthesiology, Perioperative Critical Care and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass.
| | - Alissa C Sodickson
- Department of Anesthesiology, Perioperative Critical Care and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Department of Molecular Cardiology, Lerner Research Institute Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University Cleveland Clinic, Cleveland, Ohio
| | - Albert L Waldo
- Division of Cardiovascular Medicine, Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Bernard J Gersh
- Division of Cardiovascular Diseases and Internal Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minn
| | - James E Tisdale
- Department of Pharmacy Practice, College of Pharmacy, Purdue University and Indiana University School of Medicine, Indianapolis, Ind
| | - Hugh Calkins
- Department of Medicine, Cardiac Arrhythmia Service, Johns Hopkins University, Baltimore, Md
| | - Sary Aranki
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Stephen Cassivi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minn
| | - Sidney C Smith
- Center for Heart and Vascular Care, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Dawood Darbar
- Division of Cardiovascular Medicine, Department of Medicine, Arrhythmia Service, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Jon O Wee
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Thomas K Waddell
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David Amar
- Memorial Sloan-Kettering Cancer Center, Department of Anesthesiology and Critical Care Medicine, New York, NY
| | - Dale Adler
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
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2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. Executive summary. J Thorac Cardiovasc Surg 2014; 148:772-91. [DOI: 10.1016/j.jtcvs.2014.06.037] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 11/23/2022]
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Lip GYH, Al-Khatib SM, Cosio FG, Banerjee A, Savelieva I, Ruskin J, Blendea D, Nattel S, De Bono J, Conroy JM, Hess PL, Guasch E, Halperin JL, Kirchhof P, Cosio MDG, Camm AJ. Contemporary management of atrial fibrillation: what can clinical registries tell us about stroke prevention and current therapeutic approaches? J Am Heart Assoc 2014; 3:jah3671. [PMID: 25164944 PMCID: PMC4310414 DOI: 10.1161/jaha.114.001179] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Center for Cardiovascular Sciences, City Hospital, Birmingham, UK (G.H.L., A.B.)
| | - Sana M Al-Khatib
- Department of Medicine, Cardiology Division, Duke University Medical Center, Durham, NC (S.M.A.K., P.L.H.)
| | - Francisco G Cosio
- Cardiología Department, Hospital Universitario de Getafe, Madrid, Spain (F.G.C.)
| | - Amitava Banerjee
- University of Birmingham Center for Cardiovascular Sciences, City Hospital, Birmingham, UK (G.H.L., A.B.)
| | - Irina Savelieva
- Division of Clinical Sciences, Cardiovascular Science, St George's University of London and Imperial College, London, UK (I.S., J.C.)
| | - Jeremy Ruskin
- Department of Medicine, Massachusetts General Hospital, Boston, MA (J.R., D.B.)
| | - Dan Blendea
- Department of Medicine, Massachusetts General Hospital, Boston, MA (J.R., D.B.)
| | - Stanley Nattel
- Montreal Heart Institute, Montreal, Quebec, Canada (S.N., E.G.)
| | - Joseph De Bono
- University Hospitals Birmingham NHS Trust, Birmingham, UK (J.D.B.)
| | - Jennifer M Conroy
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, NY (J.M.C., J.L.H.)
| | - Paul L Hess
- Department of Medicine, Cardiology Division, Duke University Medical Center, Durham, NC (S.M.A.K., P.L.H.)
| | - Eduard Guasch
- Montreal Heart Institute, Montreal, Quebec, Canada (S.N., E.G.)
| | - Jonathan L Halperin
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, NY (J.M.C., J.L.H.)
| | - Paulus Kirchhof
- University of Birmingham Center for Cardiovascular Sciences, University of Birmingham and Sandwell and West Birmingham NHS Trust, Birmingham, UK (P.K.) Department of Cardiology and Angiology, Hospital of the University of Münster, Münster, Germany (P.K.) German Atrial Fibrillation Competence NETwork (AFNET), Münster, Germany (P.K.)
| | - M Dolores G Cosio
- Heart Failure and Cardiac Transplant Unit, Cardiology Hospital Santa Creu i Sant Pau, Barcelona, Spain (D.C.)
| | - A John Camm
- Division of Clinical Sciences, Cardiovascular Science, St George's University of London and Imperial College, London, UK (I.S., J.C.)
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Shah M, Avgil Tsadok M, Jackevicius CA, Essebag V, Behlouli H, Pilote L. Relation of digoxin use in atrial fibrillation and the risk of all-cause mortality in patients ≥65 years of age with versus without heart failure. Am J Cardiol 2014; 114:401-6. [PMID: 24950677 DOI: 10.1016/j.amjcard.2014.05.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 05/01/2014] [Accepted: 05/01/2014] [Indexed: 01/18/2023]
Abstract
Previous studies on digoxin use in patients with atrial fibrillation (AF) and the risk of all-cause mortality found conflicting results. We conducted a population-based, retrospective, cohort study of patients aged ≥65 years admitted to a hospital with a primary or secondary diagnosis of AF, in Quebec province, Canada, from 1998 to 2012. The AF cohort was grouped into patients with and without heart failure (HF) and into digoxin and no-digoxin users according to the first prescription filled for digoxin within 30 days after AF hospital discharge. We derived propensity score-matched digoxin and no-digoxin treatment groups for the groups of patients with and without HF, respectively, and conducted multivariable Cox proportional hazards regression analyses to determine association between digoxin use and all-cause mortality. The AF propensity score-matched cohorts of patients with and without HF were well balanced on baseline characteristics. In the propensity score-matched HF group, digoxin use was associated with a 14% greater risk of all-cause mortality (adjusted hazard ratio 1.14, 95% confidence interval 1.10 to 1.17). In the propensity score-matched no-HF group, digoxin use was associated with a 17% greater risk of all-cause mortality (adjusted hazard ratio 1.17, 95% confidence interval 1.14 to 1.19). In conclusion, our retrospective analyses found that digoxin use was associated with a greater risk for all-cause mortality in patients aged ≥65 years with AF regardless of concomitant HF. Large, multicenter, randomized controlled trials or prospective cohort studies are required to clarify this issue.
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Browne SD, McMaster J, Rizvi SA, Ahmed S. End-stage renal disease with atrial fibrillation: uncharted territory in the modern world of anticoagulants. Expert Opin Pharmacother 2014; 15:1639-42. [PMID: 25032883 DOI: 10.1517/14656566.2014.936379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Herrington W, Haynes R, Staplin N, Emberson J, Baigent C, Landray M. Evidence for the prevention and treatment of stroke in dialysis patients. Semin Dial 2014; 28:35-47. [PMID: 25040468 PMCID: PMC4320775 DOI: 10.1111/sdi.12281] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The risks of both ischemic and hemorrhagic stroke are particularly high in dialysis patients of any age and outcomes are poor. It is therefore important to identify strategies that safely minimize stroke risk in this population. Observational studies have been unable to clarify the relative importance of traditional stroke risk factors such as blood pressure and cholesterol in those on dialysis, and are affected by biases that usually make them an inappropriate source of data on which to base therapeutic decisions. Well-conducted randomized trials are not susceptible to such biases and can reliably investigate the causal nature of the association between a potential risk factor and the outcome of interest. However, dialysis patients have been under-represented in the cardiovascular trials which have proven net benefit of commonly used preventative treatments (e.g., antihypertensive treatments, low-dose aspirin, carotid revascularization, and thromboprophylaxis for atrial fibrillation), and there remains uncertainty about safety and efficacy of many of these treatments in this high-risk population. Moreover, the efficacy of renal-specific therapies that might reduce cardiovascular risk, such as modulators of mineral and bone disorder, online hemodiafiltration, and daily (nocturnal) hemodialysis, have not been tested in adequately powered trials. Recent trials have also demonstrated how widespread current practices could be causing stroke. Therefore, it is important that reliable information on the prevention and treatment of stroke (and other cardiovascular disease) in dialysis patients is generated by performing large-scale randomized trials of many current and future treatments.
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Affiliation(s)
- William Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Oxford Kidney Unit, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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Chao TF, Liu CJ, Wang KL, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chung FP, Liao JN, Chen TJ, Lip GYH, Chen SA. Incidence and prediction of ischemic stroke among atrial fibrillation patients with end-stage renal disease requiring dialysis. Heart Rhythm 2014; 11:1752-9. [PMID: 24952148 DOI: 10.1016/j.hrthm.2014.06.021] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Renal dysfunction is a significant risk factor for ischemic stroke in atrial fibrillation (AF). However, the incidence of ischemic stroke and how to predict its occurrence among AF patients with end-stage renal disease (ESRD) are unclear. OBJECTIVE The purpose of this study was to compare the CHADS2 and CHA2DS2-VASc scores for stroke risk stratification in AF patients with ESRD. METHODS A total of 10,999 AF patients with ESRD undergoing renal replacement therapy who were not receiving oral anticoagulants or antiplatelet agents were identified from Taiwan's National Health Insurance Research Database. The study end-point was occurrence of ischemic stroke. RESULTS The median (interquartile) CHADS2 and CHA2DS2-VASc scores for the study cohort were 3 (2-5) and 5 (4-7), respectively. During follow-up, 1217 patients (11.7%) experienced ischemic stroke, with an incidence rate of 6.9 per 100 person-years. In Cox regression models, the CHADS2 and CHA2DS2-VASc scores both were significant predictors of ischemic stroke. C-indexes for CHADS2 and CHA2DS2-VASc were 0.608 and 0.682, respectively (P < .001). CHA2DS2-VASc improved the net reclassification index by 4.8% compared with CHADS2 (P < .0001). Among 1409 patients with a CHADS2 score of 0 or 1, the CHA2DS2-VASc score ranged from 1 to 4, with event rates ranging from 2.1 to 4.7 per 100 person-years. CONCLUSION The CHA2DS2-VASc score was useful in predicting ischemic stroke in AF patients with ESRD undergoing dialysis and was superior to the CHADS2 score. The net clinical benefit balancing stroke reduction against major bleeding with anticoagulation in these high-risk patients remains to be defined.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Jen Liu
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kang-Ling Wang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
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