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Niehues P, Wolfes J, Wegner FK, Ellermann C, Rath B, Eckardt L. Use of direct oral anticoagulants in patients on chronic hemodialysis: Contemporary appraisal on the role for patients with atrial fibrillation. Trends Cardiovasc Med 2024; 34:446-450. [PMID: 38043918 DOI: 10.1016/j.tcm.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/08/2023] [Accepted: 11/26/2023] [Indexed: 12/05/2023]
Abstract
Atrial fibrillation (AF) is common in patients with chronic kidney disease (CKD) undergoing hemodialysis and in this patient population, management in terms of oral anticoagulation (OAC) presents unique challenges due to the increased risk of both thromboembolic events and bleeding complications. The attributable risk of AF for stroke may differ from patients without CKD, raising the question if OAC is indicated at all. Historically, vitamin K antagonists (VKA) have been the standard treatment for anticoagulation in AF; however, direct oral anticoagulants (DOACs) have emerged as an alternative therapeutic option, whereby data from prospective randomised trials with hemodialysis patients is limited resulting in great variability of practice and guideline recommendations. This review summarizes existing data sources regarding the use and benefit of oral anticoagulation with VKA and DOAC in hemodialysis patients.
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Affiliation(s)
- Philipp Niehues
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster 48149, Germany
| | - Julian Wolfes
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster 48149, Germany
| | - Felix K Wegner
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster 48149, Germany
| | - Christian Ellermann
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster 48149, Germany
| | - Benjamin Rath
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster 48149, Germany
| | - Lars Eckardt
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Muenster 48149, Germany.
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Wang X, Sin CF, Teo KC, Leung WCY, Wong YK, Liu RKC, Fok JW, Ip BY, Kwan HH, Lee TC, Sheng B, Yip EKK, Yap DYH, Luo H, Lau KK. Impact of renal function variability on long-term prognosis in ischemic stroke patients with atrial fibrillation. Front Neurol 2024; 15:1294022. [PMID: 38711560 PMCID: PMC11071668 DOI: 10.3389/fneur.2024.1294022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 03/25/2024] [Indexed: 05/08/2024] Open
Abstract
Background Although renal dysfunction is associated with adverse clinical outcomes in patients with atrial fibrillation (AF) following stroke, the impact of renal function variability is unclear. Aim This study aimed to assess the association between renal function variability and various adverse clinical outcomes in patients with transient ischemic attack (TIA)/ischemic stroke and atrial fibrillation (AF). Methods We conducted a population-based study and retrospectively identified patients hospitalized with a diagnosis of TIA/ischemic stroke and AF during 2016-2020 using the Clinical Data Analysis and Reporting System of Hong Kong. Serial serum creatinine tested upon the onset of TIA/ischemic stroke and during their subsequent follow-up was collected. Renal function variability was calculated using the coefficient of variation of the estimated glomerular filtration rate (eGFR). Clinical endpoints that occurred during the study period were captured and included ischemic stroke/systemic embolism, intracerebral hemorrhage (ICH), total bleeding, major adverse cardiovascular events (MACE), cardiovascular, non-cardiovascular, and all-cause mortality. Competing risk regression and Cox proportional hazard regression models were used to assess the associations of renal function variability with the outcomes of interest. Results A total of 3,809 patients (mean age 80 ± 10 years, 43% men) who satisfied the inclusion and exclusion criteria were followed up for a mean of 2.5 ± 1.5 years (9,523 patient-years). The mean eGFR was 66 ± 22 mL/min/1.73 m2 at baseline, and the median number of renal function tests per patient during the follow-up period was 20 (interquartile range 11-35). After accounting for potential confounders, a greater eGFR variability was associated with increased risks of recurrent ischemic stroke/systemic embolism [fully adjusted subdistribution hazard ratio 1.11, 95% confidence interval (CI) 1.03-1.20], ICH (1.17, 1.01-1.36), total bleeding (1.13, 1.06-1.21), MACE (1.22, 1.15-1.30), cardiovascular (1.49, 1.32-1.69), non-cardiovascular (1.43, 1.35-1.52), and all-cause mortality (fully adjusted hazard ratio 1.44, 1.39-1.50). Conclusion Visit-to-visit renal function variability is independently associated with adverse clinical outcomes in TIA/ischemic stroke patients with AF. Further large-scale studies are needed to validate our results.
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Affiliation(s)
- Xiao Wang
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chun-fung Sin
- Department of Pathology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Kay-Cheong Teo
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - William C. Y. Leung
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yuen-Kwun Wong
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Roxanna K. C. Liu
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Joshua W. Fok
- Department of Medicine, Yan Chai Hospital, Hong Kong, Hong Kong SAR, China
| | - Bonaventure Y. Ip
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Hon Hang Kwan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, Hong Kong SAR, China
| | - Tsz Ching Lee
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Bun Sheng
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, Hong Kong SAR, China
| | - Edwin Kin-Keung Yip
- Department of Medicine and Geriatrics, Ruttonjee Hospital, Hong Kong, Hong Kong SAR, China
| | - Desmond Y. H. Yap
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Hao Luo
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Computer Science, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Kui-Kai Lau
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
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Wang YT, Chen JH, Liao SF, Chen YJ, Lip GYH, Yeh JS. Cardiac and renal outcomes of direct oral anticoagulants in patients with atrial fibrillation. Eur J Clin Invest 2024; 54:e14086. [PMID: 37635402 DOI: 10.1111/eci.14086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/03/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Oral anticoagulation therapy with warfarin or direct oral anticoagulants (DOACs) is the mainstay for stroke prevention in patients with non-valvular atrial fibrillation (AF). The DOACs might have a lower risk of declining renal function than warfarin. This study aimed to compare renal outcomes among rivaroxaban, edoxaban, dabigatran, and warfarin. METHOD This cohort study identified 2203 adults with AF who started anticoagulation therapy between 1 July 2013 and 31 December 2020, in a clinical database at a single centre. Inverse probability of treatment weighting was adopted to balance baseline characteristics among four anticoagulants treatment groups. The primary outcome was a composite of cardiac and renal outcomes, involving a ≥30% decline in estimated glomerular filtration rate (eGFR), renal failure and cardiovascular death. RESULTS After propensity score weighting, dabigatran was associated with significantly lower risks of a ≥30% decline in eGFR (hazard ratio [HR]: .69, 95% confidence interval [CI]: .497-.951, p = .0237), doubling of the serum creatinine level (HR: .49, 95% CI: .259-.927, p = .0282) and the cardiac and renal outcome composite (HR: .67, 95% CI: .485-.913, p = .0115) than warfarin. Rivaroxaban and edoxaban did not show significant protective effects on renal outcomes compared to warfarin. CONCLUSION In this study, patients treated with dabigatran had significantly reduced risks of declining renal function and composite cardiac and renal events than those treated with warfarin. However, rivaroxaban and edoxaban were not associated with lower risks of any renal outcomes than warfarin. More studies are warranted to investigate and compare the impact of renal function between different DOACs in patients with AF.
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Affiliation(s)
- Yu-Ting Wang
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Jo-Hsin Chen
- Department of Pharmacy, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shu-Fen Liao
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
- Department of Medical Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Jen Chen
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jong-Shiuan Yeh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
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Armentaro G, D’Arrigo G, Bo M, Cassano V, Miceli S, Pitino A, Tripepi G, Romeo SMG, Sesti G, Lip GYH, Pastori D, Gori M, Sciacqua A. Medium-term and long-term renal function changes with direct oral anticoagulants in elderly patients with atrial fibrillation. Front Pharmacol 2023; 14:1210560. [PMID: 37469870 PMCID: PMC10352777 DOI: 10.3389/fphar.2023.1210560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 06/21/2023] [Indexed: 07/21/2023] Open
Abstract
Objective: Atrial Fibrillation (AF) and chronic kidney disease frequently coexist in the elderly. Warfarin-like drugs (WLDs) may be associated with a relatively greater decrease of estimated glomerular filtration rate (eGFR) as compared to direct oral anticoagulants (DOACs), but there is no evidence on the medium- and long-term changes. To further elucidate this issue in elderly patients with AF, we investigated the renal function deterioration in the two groups of the study (DOACs or WLDs). Patients and Methods: A total of 420 AF patients were enrolled (mean age: 77.0 ± 6.0 years; 136 on WLDs and 284 on DOACs). These patients underwent three eGFR measurements during the follow-up period. The between-arms difference of eGFR decline over time was investigated by Linear Mixed Models and group-based trajectory model analyses. Results: In the whole study cohort, after a median follow-up of 4.9 years (interquartile range: 2.7-7.0 years), eGFR decreased from 67.4 ± 18.2 to 47.1 ± 14.3 mL/min/1.73 m2 (p < 0.001). Remarkably, patients on DOACs experienced a significantly smaller eGFR decline than WLDs patients (-21.3% vs. -45.1%, p < 0.001) and this was true both in the medium-term (-6.6 vs. -19.9 mL/min/1.73 m2) and in the long-term (-13.5 versus -34.2 mL/min/1.73 m2) period. After stratification into five subgroups according to trajectories of renal function decline over time, logistic regression showed that DOACs patients had from 3.03 to 4.24-fold greater likelihood to belong to the trajectory with less marked eGFR decline over time than WLDs patients. Conclusion: Elderly patients with AF on treatment with DOACs had a relatively smaller decline of eGFR over time compared to those on treatment with WLDs. This is consistent with what was partly reported in the literature.
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Affiliation(s)
- Giuseppe Armentaro
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Graziella D’Arrigo
- Institute of Clinical Physiology (IFC-CNR), Section of Reggio Calabria, Reggio Calabria, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, Molinette Hospital, Turin, Italy
| | - Velia Cassano
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Sofia Miceli
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Annalisa Pitino
- Institute of Clinical Physiology (IFC-CNR), Section of Rome, Rome, Italy
| | - Giovanni Tripepi
- Institute of Clinical Physiology (IFC-CNR), Section of Reggio Calabria, Reggio Calabria, Italy
| | | | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, University Rome-Sapienza, Rome, Italy
| | - Gregory Y. H. Lip
- Department of Clinical MedicineAalborg University, Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, Denmark
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Mercedes Gori
- Institute of Clinical Physiology (IFC-CNR), Section of Rome, Rome, Italy
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
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Trohman RG, Huang HD, Sharma PS. Atrial fibrillation: primary prevention, secondary prevention, and prevention of thromboembolic complications: part 1. Front Cardiovasc Med 2023; 10:1060030. [PMID: 37396596 PMCID: PMC10311453 DOI: 10.3389/fcvm.2023.1060030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 03/14/2023] [Indexed: 07/04/2023] Open
Abstract
Atrial fibrillation (AF), is the most common sustained cardiac arrhythmia. It was once thought to be benign as long as the ventricular rate was controlled, however, AF is associated with significant cardiac morbidity and mortality. Increasing life expectancy driven by improved health care and decreased fertility rates has, in most of the world, resulted in the population aged ≥65 years growing more rapidly than the overall population. As the population ages, projections suggest that the burden of AF may increase more than 60% by 2050. Although considerable progress has been made in the treatment and management of AF, primary prevention, secondary prevention, and prevention of thromboembolic complications remain a work in progress. This narrative review was facilitated by a MEDLINE search to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1950 and 2021. Atrial fibrillation was searched via the terms primary prevention, hyperthyroidism, Wolff-Parkinson-White syndrome, catheter ablation, surgical ablation, hybrid ablation, stroke prevention, anticoagulation, left atrial occlusion and atrial excision. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. In these two manuscripts, we discuss the current strategies available to prevent AF, then compare noninvasive and invasive treatment strategies to diminish AF recurrence. In addition, we examine the pharmacological, percutaneous device and surgical approaches to prevent stroke as well as other types of thromboembolic events.
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Affiliation(s)
- Richard G. Trohman
- Section of Electrophysiology, Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
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Park H, Yu HT, Kim TH, Park J, Park JK, Kang KW, Shim J, Kim JB, Kim J, Choi EK, Park HW, Lee YS, Joung B. Oral Anticoagulation Therapy in Atrial Fibrillation Patients with Advanced Chronic Kidney Disease: CODE-AF Registry. Yonsei Med J 2023; 64:18-24. [PMID: 36579375 PMCID: PMC9826956 DOI: 10.3349/ymj.2022.0455] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Advanced chronic kidney disease (CKD), including end-stage renal disease (ESRD) on dialysis, increases thromboembolic risk among patients with atrial fibrillation (AF). This study examined the comparative safety and efficacy of direct-acting oral anticoagulant (DOAC) compared to warfarin or no oral anticoagulant (OAC) in AF patients with advanced CKD or ESRD on dialysis. MATERIALS AND METHODS Using data from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, 260 non-valvular AF patients with advanced CKD (defined as estimated glomerular filtration rate <30 mL/min per 1.73/m²) or ESRD on dialysis were enrolled from June 2016 to July 2020. The study population was categorized into DOAC, warfarin, and no OAC groups; and differences in major or clinically relevant non-major (CRNM) bleeding, stroke/systemic embolism (SE), myocardial infarction/critical limb ischemia (CLI), and death were assessed. RESULTS During a median 24 months of follow-up, major or CRNM bleeding risk was significantly reduced in the DOAC group compared to the warfarin group [hazard ratio (HR) 0.11, 95% confidence interval (CI) 0.01 to 0.93, p=0.043]. In addition, the risk of composite adverse clinical outcomes (major or CRNM bleeding, stroke/SE, myocardial infarction/CLI, and death) was significantly reduced in the DOAC group compared to the no OAC group (HR 0.16, 95% CI 0.03 to 0.91, p=0.039). CONCLUSION Among AF patients with advanced CKD or ESRD on dialysis, DOAC was associated with a lower risk of major or CRNM bleeding compared to warfarin and a lower risk of composite adverse clinical outcomes compared to no OAC. ClinicalTrials.gov (NCT02786095).
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Affiliation(s)
- Hanjin Park
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Junbeom Park
- Department of Cardiology, School of Medicine, Ewha Woman's University, Seoul, Korea
| | - Jin-Kyu Park
- Department of Cardiology, Hanyang University Seoul Hospital, Seoul, Korea
| | - Ki-Woon Kang
- Division of Cardiology, Eulji University Hospital, Daejeon, Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Jin-Bae Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Jun Kim
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyung Wook Park
- Department of Cardiology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Young Soo Lee
- Division of Cardiology, Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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Kirchhof P, Pecen L, Bakhai A, de Asmundis C, de Groot JR, Deharo JC, Kelly P, Levy P, Lopez-de-Sa E, Monteiro P, Steffel J, Waltenberger J, Weiss TW, Laeis P, Manu MC, Souza J, De Caterina R. Edoxaban for stroke prevention in atrial fibrillation and age-adjusted predictors of clinical outcomes in routine clinical care. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 9:47-57. [PMID: 35881467 PMCID: PMC9753092 DOI: 10.1093/ehjcvp/pvac042] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/11/2022] [Accepted: 07/22/2022] [Indexed: 11/12/2022]
Abstract
AIMS Patients with atrial fibrillation (AF) treated with oral anticoagulation still suffer from cardiovascular complications including cardiovascular death, stroke, and major bleeding. To identify risk factors for predicting stroke and bleeding outcomes in anticoagulated patients, we assessed 2-year outcomes in patients with AF treated with edoxaban in routine care. We also report the age-adjusted risk predictors of clinical outcomes. METHODS AND RESULTS The Edoxaban Treatment in Routine Clinical Practice for Patients With Non-Valvular Atrial Fibrillation (ETNA-AF) Europe (NCT02944019) is a prospective, multi-centre, post-authorisation, observational study with an overall 4-year follow-up conducted in 825 centres enrolling edoxaban-treated patients in 10 European countries. Of the 13 133 patients with AF (mean age: 73.6 ± 9.5 years), 5682 (43.3%) were female. At the 2-year follow-up, 9017/13 133 patients were still on edoxaban; 1830 discontinued treatment including 937 who died (annualised event rate of all-cause death was 3.87%). 518 (2.14%) patients died of cardiovascular causes; 234 (0.97%) experienced major bleeding and 168 (0.70%) experienced stroke or systemic embolic events (SEE). Intracranial haemorrhage was noted in 49 patients (0.20%). History of transient ischaemic attack (TIA) at baseline was the strongest predictor of ischaemic stroke or SEE (Wald χ2: 73.63; P < 0.0001). Low kidney function at baseline was the strongest predictor of major bleeding (Wald χ2: 30.68; P < 0.0001). History of heart failure (HF) was the strongest predictor of all-cause (Wald χ2: 146.99; P < 0.0001) and cardiovascular death (Wald χ2: 100.38; P < 0.0001). CONCLUSION Patients treated with edoxaban in ETNA-AF-Europe reported low 2-year event rates in unselected AF patients. Prior stroke, reduced kidney function, and HF identify patients at high risk of stroke, bleeding and all-cause/cardiovascular death, respectively.
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Affiliation(s)
- Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, IBR 136, Wolfson Drive, Birmingham B15 2TT, UK
- Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Sciences (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
| | - Ladislav Pecen
- Department of Statistical Modelling, Institute of Computer Science of the Czech Academy of Sciences, Pod Vodarenskou vezi 271/2, 182 07 Prague, Czech Republic
| | - Ameet Bakhai
- Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Brussels, Belgium
| | - Joris R de Groot
- Amsterdam UMC location University of Amsterdam, Cardiology, Meibergrdreef 9, 1105 AZ Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, 1105 AZ Amsterdam, the Netherlands
| | - Jean Claude Deharo
- AP-HM, Aix Marseille University, Hospital Timone, Cardiologie, Rythmologie, 264 rue Saint-Pierre, 13005, Marseille, France
| | - Peter Kelly
- Department of Neurology, HRB Stroke Clinical Trials Network Ireland, University College Dublin/Mater Misericordiae University Hospital, Eccles St, Northside, D07 R2WY Dublin, Ireland
| | - Pierre Levy
- Department of Economics, Universite Paris-Dauphine, PSL Research University, LEDa-LEGOS, 75775 Paris, France
| | - Esteban Lopez-de-Sa
- Cardiological Intensive Care Unit, Cardiology Service, Hospital Universitario La Paz, IDIPAZ, CIBERCV, 28046 Madrid, Spain
| | - Pedro Monteiro
- Department of Cardiology, Centro Hospitalar e Universitario de Coimbra, Praceta Mota Pinto 3000-075 Coimbra, Portugal
| | - Jan Steffel
- Department of Cardiology and Invasive Electrophysiology, Heart Clinic Hirslanden, Witellikerstrasse 40, 8032 Zürich, Switzerland
| | - Johannes Waltenberger
- Chair of Cardiology and Vascular Medicine, University of Munster, Schlossplatz 2, 48149 Munster, Germany
- Diagnostic and Therapeutic Heart Center, Kappelistr. 35, 8002 Zurich, Switzerland
| | - Thomas W Weiss
- Institute for Cardiometabolic Diseases, Karl Landsteiner Society, 3100 St. Polten, Austria
| | - Petra Laeis
- Daiichi Sankyo Europe GmbH, Zielstattstr. 48, 81379 Munich, Germany
| | | | - José Souza
- Daiichi Sankyo Europe GmbH, Zielstattstr. 48, 81379 Munich, Germany
| | - Raffaele De Caterina
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, First Division of Cardiology, Pisa University Hospital, 56124 Pisa, Italy; and Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy
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Schettler V, Schlieper G. Gerinnungsmanagement in der schweren, fortgeschrittenen Niereninsuffizienz. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1949-8104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ZusammenfassungPatienten mit chronischer Niereninsuffizienz (CKD) haben ein hohes Risiko für nicht valvuläres Vorhofflimmern (NVAF) und häufig ein höheres Risiko für venöse Thromboembolien (VTE) aufgrund
ihrer Grunderkrankungen wie z. B. Diabetes. Bisher kamen Vitamin-K-Antagonisten (VKA) auch bei diesen Patienten in Deutschland zum Einsatz. VKA haben ein erhöhtes Blutungsrisiko und werden
als Risikofaktor für eine Verschlechterung der Nierenfunktion und/oder Gefäßsituation (Athero- und Mediasklerose) von Patienten diskutiert. Aus diesen Gründen und den vorliegenden
Studiendaten werden deshalb direkt wirkende orale Antikoagulanzien (DOAC) auch bei Patienten mit NVAF und CKD (G1–G3) in den Leitlinien empfohlen. Allerdings kann keine klare Empfehlung für
den Einsatz von DOAC bei Dialysepatienten gegeben werden. Heparine spielen in diesem Zusammenhang nur eine untergeordnete Rolle.
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Affiliation(s)
| | - Georg Schlieper
- Zentrum für Nieren-, Hochdruck- und Stoffwechselerkrankungen, Hannover, Deutschland
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Escobar A, Salem AM, Dickson K, Johnson TN, Burk KJ, Bashoura L, Faiz SA. Anticoagulation and bleeding in the cancer patient. Support Care Cancer 2022; 30:8547-8557. [PMID: 35579752 PMCID: PMC9529787 DOI: 10.1007/s00520-022-07136-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
Abstract
Cancer patients have an increased risk of bleeding compared to non-cancer patients with anticoagulant therapy. A bleeding risk assessment before initiation of anticoagulation is recommended. Currently low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) are the mainstays of treatment for cancer-associated venous thromboembolism (VTE). Since DOACs are administered orally, they offer some convenience and ease of administration; however, LMWH may be preferred in certain cancers. Given the prevalence of anticoagulant therapies in cancer patients, clinical providers must be able to recognize potentially critical bleeding sites and modalities to reverse major hemorrhage. Reversal agents or antidotes to bleeding may be required when bleeding is persistent or life-threatening. These include vitamin K, fresh frozen plasma (FFP), protamine, prothrombin complex concentrate (PCC) or andexanet alfa, and idarucizumab. Inferior vena cava (IVC) filter insertion can be also considered in those with major bleeding. Evidence for timing and need for re-initiation of anticoagulant therapy after a major bleeding remains sparse, but a multi-disciplinary approach and shared decision-making can be implemented in the interim.
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Affiliation(s)
- Andres Escobar
- Divisions of Critical Care, Pulmonary and Sleep Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Ahmed M Salem
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kodwo Dickson
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tami N Johnson
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathyrn J Burk
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lara Bashoura
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA
| | - Saadia A Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA.
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10
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Gue YX, Bisson A, Bodin A, Herbert J, Lip GYH, Fauchier L. Season of Birth and Cardiovascular Mortality in Atrial Fibrillation: A Population-Based Cohort Study. J Cardiovasc Dev Dis 2021; 8:jcdd8120177. [PMID: 34940532 PMCID: PMC8707232 DOI: 10.3390/jcdd8120177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022] Open
Abstract
Background: The fetal origins hypothesis have associated early life exposures with the development of adverse health outcomes in adulthood. Season of birth has been shown to be associated with overall and cardiovascular mortality. Methods: We performed a retrospective database study to explore the association between season of birth and mortality in patients with atrial fibrillation. Results: A total of 8962 patients with AF were identified in the database with 1253 deaths recorded. AF patients born in spring and summer had a higher mortality rate when compared to those born in autumn and winter (hazard ratio (HR) 1.13, 95% confidence interval (CI) 1.01–1.26, p = 0.03). This effect was consistent in the male subgroup (HR 1.25, 95% CI 1.03–1.51, p = 0.02 for males born in spring; HR 1.24, 95% CI 1.03–1.51, p = 0.03 for males born in summer when compared to winter as the reference) but not in females (HR 1.02, 95% CI 0.79–1.31, p = 0.88 for females born in spring; HR 1.11, 95% CI 0.87–1.42, p = 0.39 for females born in summer when compared to winter as the reference). Results persisted after adjustment for baseline characteristics and clinical risk profile. A similar pattern was observed with cardiovascular mortality. Conclusion: Birth in spring or summer is associated with a higher risk of cardiovascular mortality in male AF patients, but not in females. This could be related to the underlying differences in rates of major adverse clinical events between genders. Further studies should aim at clarifying the mechanisms behind this association, which may help us understand the higher level of risk in female patients with AF.
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Affiliation(s)
- Ying X. Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; (Y.X.G.); (G.Y.H.L.)
| | - Arnaud Bisson
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (J.H.)
| | - Alexandre Bodin
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (J.H.)
| | - Julien Herbert
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (J.H.)
- Service d’Information Médicale, d’Épidémiologie et d’Économie de la Santé, Centre Hospitalier Universitaire et Faculté de Médecine, EA7505, Université de Tours, 37044 Tours, France
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK; (Y.X.G.); (G.Y.H.L.)
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (J.H.)
- Correspondence: ; Tel.: +33-247474650; Fax: +33-247475919
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11
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Chronic kidney disease and risks of adverse clinical events in patients with atrial fibrillation. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2021; 18:867-876. [PMID: 34908924 PMCID: PMC8648544 DOI: 10.11909/j.issn.1671-5411.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is highly prevalent in patients with atrial fibrillation (AF). However, the association between CKD and clinical consequences in AF patients is still under debate. METHODS We included 19,079 nonvalvular AF patients with available estimated glomerular filtration rate (eGFR) values in the Chinese Atrial Fibrillation Registry from 2011 to 2018. Patients were classified into no CKD (eGFR ≥ 90 mL/min per 1.73 m2), mild CKD (60 ≤ eGFR < 90 mL/min per 1.73 m 2), moderate CKD (30 ≤ eGFR < 60 mL/min per 1.73 m 2), and severe CKD (eGFR < 30 mL/min per 1.73 m 2) groups. The risks of thromboembolism, major bleeding, and cardiovascular mortality were estimated with Fine-Gray regression analysis according to CKD status. Cox regression was performed to assess the risk of all-cause mortality associated with CKD. RESULTS Over a mean follow-up of 4.1 ± 1.9 years, there were 985 thromboembolic events, 414 major bleeding events, 956 cardiovascular deaths, and 1,786 all-cause deaths. After multivariate adjustment, CKD was not an independent risk factor of thromboembolic events. As compared to patients with no CKD, those with mild CKD, moderate CKD, and severe CKD had a 45%, 47%, and 133% higher risk of major bleeding, respectively. There was a graded increased risk of cardiovascular mortality associated with CKD status compared with no CKD group: adjusted hazard ratio [HR] was 1.34 (95% CI: 1.07-1.68,P = 0.011) for mild CKD group, 2.17 (95% CI: 1.67-2.81,P < 0.0001) for moderate CKD group, and 2.95 (95% CI: 1.97-4.41, P < 0.0001) for severe CKD group, respectively. Risk of all-cause mortality also increased among patients with moderate or severe CKD. CONCLUSIONS CKD status was independently associated with progressively higher risks of major bleeding and mortality, but didn't seem to be an independent predictor of thromboembolism in AF patients.
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12
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Lip GYH, Gue Y, Zhang J, Chao TF, Calkins H, Potpara T. Stroke Prevention in Atrial Fibrillation. Trends Cardiovasc Med 2021; 32:501-510. [PMID: 34619337 DOI: 10.1016/j.tcm.2021.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 10/20/2022]
Abstract
Atrial fibrillation (AF) is the commonest sustained cardiac rhythm disorder associated with an increased risk of stroke and systemic embolic events. The prevention of stroke using oral anticoagulants has been a pivotal component of AF management. The purpose of this review is to summarize recent advances in the treatment and prevention of stroke in AF over the last 5 years. We performed a comprehensive structured literature search using MEDLINE for publications from 11th March 2015 through to 31st December 2020. We focused mainly on primarily published research articles and systematic reviews including updates in different international guidelines. We found that improved awareness and detection of AF and use of clinical risk stratification are central to the identification of patients at risk of stroke who would benefit from oral anticoagulation. The recommendation of non-vitamin K antagonist oral anticoagulants over warfarin in both efficacy and safety perspective is represented in all international guidelines. Beyond stroke prevention, there is a move to more holistic or integrated care management of AF, which has been shown to improve outcomes. We conclude that stroke prevention remains a dominant part of the management of patients with AF. Not all stroke risk factors carry equal weight, and many require additional scrutiny (e.g. severity of CAD, type of diabetes, duration of hypertension). The utilization of clinical risk scores to help decision-making should take into account that these scores are mere simplification tools to aid decision-making and the additional clinical benefit with more complex risk scores and addition of biomarkers is limited. Also, stroke and bleeding risks are dynamic and require regular review. Instead of arbitrarily categorizing patients into (artificial) low, moderate, and high stroke risk strata, anticoagulation should be offered to all patients with AF unless they are low risk with no risk factors for stroke. Stroke prevention is also part of the proactive, integrated care approach to holistic management of patients with AF, which can be simplified in the ABC (Atrial fibrillation Better Care) pathway: 'A' Avoid stroke/Anticoagulation; 'B' Better symptom management emphasising patient-centred symptom directed decisions on rate or rhythm control strategies; and 'C' refers to Cardiovascular risk and comorbidity optimization, including lifestyle changes and attention to patient values and preferences, as well as the psychological morbidity associated with AF.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Ying Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Juqian Zhang
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - 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
| | - Hugh Calkins
- Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore MD USA
| | - Tatjana Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
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13
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Cases A, Gomez P, Broseta JJ, Perez Bernat E, Arjona Barrionuevo JDD, Portolés JM, Gorriz JL. Non-valvular Atrial Fibrillation in CKD: Role of Vitamin K Antagonists and Direct Oral Anticoagulants. A Narrative Review. Front Med (Lausanne) 2021; 8:654620. [PMID: 34604247 PMCID: PMC8484537 DOI: 10.3389/fmed.2021.654620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in chronic kidney disease (CKD), with a close bidirectional relationship between the two entities. The presence of CKD in AF increases the risk of thromboembolic events, mortality and bleeding. Vitamin K antagonists (VKA) have been the mainstay of treatment for the prevention of thromboembolic events in AF until recently, with confirmed benefits in AF patients with stage 3 CKD. However, the risk-benefit profile of VKA in patients with AF and stages 4-5 CKD is controversial due to the lack of evidence from randomized controlled trials. Treatment with VKA in CKD patients has been associated with conditions such as poorer anticoagulation quality, increased risk of bleeding, faster progression of vascular/valvular calcification and higher risk of calciphylaxis. Direct oral anticoagulants (DOACs) have shown equal or greater efficacy in stroke/systemic embolism prevention, and a better safety profile than VKA in post-hoc analysis of the pivotal randomized controlled trials in patients with non-valvular AF and stage 3 CKD, yet evidence of its risk-benefit profile in more advanced stages of CKD is scarce. Observational studies associate DOACs with a good safety/effectiveness profile compared to VKA in non-dialysis CKD patients. Further, DOACs have been associated with a lower risk of acute kidney injury and CKD development/progression than VKA. This narrative review summarizes the evidence of the efficacy and safety of warfarin and DOACs in patients with AF at different CKD stages, as well as their effects on renal function, vascular/valvular calcification and bone health.
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Affiliation(s)
- Aleix Cases
- Departament de Medicina, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Pablo Gomez
- Unidad de Factores de Riesgo Vascular, Servicio de Nefrología, Hospital Universitario de Jerez, Jerez de la Frontera, Spain
| | | | | | | | | | - Jose Luis Gorriz
- Departament de Medicina, Universitat de Valencia, Valencia, Spain
- Hospital Clínico Universitario de Valencia, Valencia, Spain
- Instituto de Investigación del Hospital Clinico Universitario, Valencia (INCLIVA), Valencia, Spain
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14
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Savic L, Mrdovic I, Asanin M, Stankovic S, Krljanac G, Lasica R, Viduljevic M. Impact of kidney function on the occurrence of new-onset atrial fibrillation in patients with ST-elevation myocardial infarction. Anatol J Cardiol 2021; 25:638-645. [PMID: 34498595 DOI: 10.5152/anatoljcardiol.2021.35332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE In this study, we aimed to examine the prognostic impact of decreased kidney function at admission on the occurrence of new-onset atrial fibrillation (AF) in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI). METHODS The study enrolled 3,115 consecutive patients with STEMI. Kidney function was assessed by estimation of the glomerular filtration rate (eGFR) at admission. Patients with cardiogenic shock at admission, patients on hemodialysis, and patients with a medical history of previous AF (paroxysmal, persistent, or permanent) were excluded. The follow-up period was six years. RESULTS New-onset AF occurred in 215 (6.9%) patients, 75 (34.9%) patients presented with AF, and 140 (65.1%) patients developed AF after pPCI. The median time of AF occurrence in patients who did not present with AF was 4.5 (interquartile range 1-25) hours after pPCI. New-onset AF was associated with a higher short- and long-term mortality. In the multiple logistic regression analysis, all stages of reduced kidney function were independent predictors for the occurrence of new-onset AF, and negative prognostic impact increased with the deterioration of kidney function: eGFR <90 mL/min/m2, hazard ratio (HR) 1.96, 95% confidence interval (CI) 1.42-2.89, p=0.011; eGFR 60-89 mL/min/m2, HR 1.54, 95% CI 1.13-2.57, p=0.045; eGFR 45-59 mL/min/m2-, HR 2.09, 95% CI 1.24-2.85, p=0.023; eGFR 30-44 mL/min/m2-, HR 2.93, 95% CI 1.64-5.29, p<0.001; eGFR 15-29 mL/min/m2-, HR 5.51, 95% CI 2.67-11.39, p<0.001. CONCLUSION Decreased kidney function was significantly associated with the occurrence of new-onset AF, and its impact increased with the deterioration in kidney function, starting with an eGFR value of 90 mL/min/m2. New-onset AF was an independent predictor of long-term all-cause mortality in the analyzed patients.
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Affiliation(s)
- Lidija Savic
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit and Cardiology Clinic, Belgrade, Serbia
| | - Igor Mrdovic
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit and Cardiology Clinic, Belgrade, Serbia
| | - Milika Asanin
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit and Cardiology Clinic, Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, Emergency Hospital, University Clinical Center of Serbia, Belgrade, Serbia
| | - Gordana Krljanac
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit and Cardiology Clinic, Belgrade, Serbia
| | - Ratko Lasica
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit and Cardiology Clinic, Belgrade, Serbia
| | - Mihajlo Viduljevic
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit and Cardiology Clinic, Belgrade, Serbia
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15
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Kotalczyk A, Ding WY, Wong CF, Rao A, Gupta D, Lip GYH. Atrial Fibrillation in Patients with Chronic Kidney Disease. Cardiol Clin 2021; 39:435-446. [PMID: 34247756 DOI: 10.1016/j.ccl.2021.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
There is a bidirectional relationship between atrial fibrillation (AF) and chronic kidney disease (CKD), with multiple shared risk factors. This article discusses an integrated care approach toward the management of patients with AF, including those with CKD. There is an increasing risk of both ischemic stroke and bleeding with progressive deterioration of renal function, complicating the decision of optimal stroke prevention strategies among patients with AF and CKD. The optimal stroke prevention strategy in patients with AF and severe CKD remains uncertain. An individualized approach incorporating stroke and bleeding risk stratification is needed, especially in those with end-stage renal disease.
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Affiliation(s)
- Agnieszka Kotalczyk
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, M. Sklodowskiej-Curie 7, Zabrze 41-800, Poland
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Christopher F Wong
- Department of Renal Medicine, Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK
| | - Anirudh Rao
- Department of Renal Medicine, Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, Aalborg 9000, Denmark.
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16
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Larina VN, Oynotkinova OS, Majorova AP, Egiazarian GA, Demidova TY. An Integrated Approach to the Management of a Multimorbid Patient with Atrial Fibrillation from the Standpoint of Modern Guidelines: Rivaroxaban is in Focus. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-06-05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation (AF) is a complex pathology that requires an integrated approach in both diagnosis and treatment, including optimal prevention of thrombosis, control of clinical symptoms, and identification and treatment of cardiovascular risk factors and comorbidities. The article analyzes some of the new positions of the recommendations of the European Society of Cardiology on atrial fibrillation, presented in 2020. Effective diagnostic and therapeutic approaches are discussed in the management of patients with AF in conditions of multimorbidity. The basic principles of the CC to ABC concept, introduced with the aim of improving a structured approach to the treatment of patients with AF, and the 4S-AF regimen necessary for decision on the use of oral anticoagulants, choosing a method of control of the rhythm and / or its frequency, choosing between ablation, cardioversion and antiarrhythmic drugs, as well as to determine the mode of treatment of major cardiovascular diseases. To improve the prognosis and achieve the best results in these patients, the most important is to reduce the risk of stroke, control cardiovascular risks and comorbidities, and ensure high adherence to the therapy within the framework of the concept of comprehensive patient protection. Rivaroxaban is considered by the authors of the article as one of the drugs that provides comprehensive anticoagulant protection of patients with AF. The efficacy profile of rivaroxaban in the prevention of acute cerebrovascular accident and high safety rates were confirmed in a population of multimorbid AF patients of different ages and the highest risk of stroke and / or bleeding.
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Affiliation(s)
| | - O. Sh. Oynotkinova
- Pirogov National Research Medical University; Research Institute of Healthcare Organization and Medical Management; Moscow State University named after M.V. Lomonosov
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17
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Cheng WH, Chan YH, Liao JN, Kuo L, Chen SA, Chao TF. Optimal Management of Anticoagulation Therapy in Asian Patients With Atrial Fibrillation. Circ J 2021; 85:1245-1253. [PMID: 34092760 DOI: 10.1253/circj.cj-21-0399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Stroke prevention is the cornerstone of management of atrial fibrillation (AF), and non-vitamin K antagonist oral anticoagulants (NOACs) are commonly prescribed. Because routine monitoring of anticoagulant effects of NOACs is not necessary, appropriate dosing following the criteria of each NOACs defined in pivotal randomized trials is important. Real-world data demonstrate that underdosing NOACs is associated with a higher risk of ischemic stroke without a lower risk of major bleeding. Furthermore, renal function of AF patients should be assessed using the Cockcroft-Gault formula to prevent overestimation that could result in overdosing of NOACs. The assessment of bleeding risk is important, and the HAS-BLED score should be used to help identify patients at high risk of bleeding (HAS-BLED score ≥3). Moreover, the HAS-BLED score should be reassessed at periodic intervals to address potentially modifiable bleeding risk factors because bleeding risks of AF patients are not static. When managing NOAC-related bleeding episodes, the possibility of occult malignancies (e.g., grastrointestinal [GI] tract cancers for patients experiencing GI bleeding and bladder cancer for patients with hematuria) should be kept in mind. Addressing all of these issues is crucial to achieving better clinical outcomes for anticoagulated AF patients. More efforts are necessary to incorporate clear and easy-to-follow recommendations about optimal management of anticoagulation into the guidelines to improve AF patient care.
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Affiliation(s)
- Wen-Han Cheng
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital.,College of Medicine, Chang Gung University.,Microscopy Core Laboratory, Chang Gung Memorial Hospital
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University
| | - Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University.,Cardiovascular Center, Taichung Veterans General Hospital
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University
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Nelson JA, Gue YX, Christensen JM, Lip GYH, Ramakrishna H. Analysis of the ESC/EACTS 2020 Atrial Fibrillation Guidelines With Perioperative Implications. J Cardiothorac Vasc Anesth 2021; 36:2177-2195. [PMID: 34130901 DOI: 10.1053/j.jvca.2021.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 11/11/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide, with an individual lifetime risk of approximately 37% in the United States. Broadly defined as a supraventricular tachyarrhythmia with disorganized atrial activation, AF results in an increased risk of stroke, heart failure, valvular heart disease, and impaired quality of life, and confers a significant burden on the health of individuals and society. AF in the perioperative setting is common and a significant source of perioperative morbidity and mortality worldwide. The latest iteration of the European Society of Cardiology AF guidelines published in 2020 provide the clinician a valuable road map for the management of this arrythmia. This expert review will comprehensively analyze the 2020 European Society of Cardiology guidelines and provide perioperative management tools for the clinician.
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Affiliation(s)
- James A Nelson
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Jon M Christensen
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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20
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5463] [Impact Index Per Article: 1821.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Magnocavallo M, Bellasi A, Mariani MV, Fusaro M, Ravera M, Paoletti E, Di Iorio B, Barbera V, Della Rocca DG, Palumbo R, Severino P, Lavalle C, Di Lullo L. Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy. J Clin Med 2020; 10:jcm10010083. [PMID: 33379379 PMCID: PMC7796391 DOI: 10.3390/jcm10010083] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.
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Affiliation(s)
- Michele Magnocavallo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Antonio Bellasi
- Department of Research, Innovation and Brand Reputation, ASST-Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Maria Fusaro
- National Council of Research, Institute of Clinical Physiology, 56124 Pisa, Italy;
| | - Maura Ravera
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Ernesto Paoletti
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Biagio Di Iorio
- Department of Nephrology and Dialysis, Moscati Hospital, 83100 Avellino, Italy;
| | - Vincenzo Barbera
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
| | | | - Roberto Palumbo
- Department of Nephrology and Dialysis, Sant’Eugenio Hospital, 00144 Rome, Italy;
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
- Correspondence: ; Fax: +39-06-972233213
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Abstract
Effective stroke prevention with oral anticoagulation (OAC) is the cornerstone of the management of patients with atrial fibrillation. The use of OAC reduces the risk of stroke and death. For most patients with atrial fibrillation without moderate or severe mitral valve stenosis or prosthetic mechanical heart valves, treatment options include vitamin K antagonists, such as warfarin, and non-vitamin K antagonist oral anticoagulants (NOACs). Although most guidelines generally recommend NOACs as the first-line OAC, caution is required in some groups of patients with atrial fibrillation at high risk of stroke and bleeding who have been under-represented or not studied in the randomized clinical trials on NOACs for stroke prevention. In addition to OAC, non-pharmacological, percutaneous therapies, including left atrial appendage occlusion, for stroke prevention have emerged, sometimes used in combination with catheter ablation for the treatment of the atrial fibrillation. High-risk groups of patients with atrial fibrillation include patients with end-stage renal failure (including those receiving dialysis), extremely old patients (such as those aged >80 years with multiple risk factors for bleeding), patients with dementia or those living in a long-term care home, patients with previous intracranial bleeding or recent acute bleeding (such as gastrointestinal bleeding), patients with acute ischaemic stroke and patients with an intracardiac thrombus. This Review provides an overview of stroke prevention strategies, including left atrial appendage occlusion, in patients with atrial fibrillation at high risk of stroke and bleeding.
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How I assess and manage the risk of bleeding in patients treated for venous thromboembolism. Blood 2020; 135:724-734. [PMID: 31951652 DOI: 10.1182/blood.2019001605] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/23/2019] [Indexed: 12/13/2022] Open
Abstract
For patients with venous thromboembolism (VTE), prediction of bleeding is relevant throughout the course of treatment, although the means and goal of this prediction differ between the subsequent stages of treatment: treatment initiation, hospital discharge, 3-month follow-up, and long-term follow-up. Even in the absence of fully established risk prediction schemes and outcome studies using a prediction scheme for treatment decisions, the present evidence supports screening for and targeting of modifiable risk factors for major bleeding, as well as the application of decision rules to identify patients at low risk of bleeding complications, in whom long-term anticoagulant treatment is likely safe. Moving forward, prediction tools need to be incorporated in well-designed randomized controlled trials aiming to establish optimal treatment duration in patients at high risk of recurrent VTE. Moreover, the benefit of their longitudinal assessment rather than application as stand-alone baseline assessments should be studied, because changes in bleeding risk over time likely constitute the best predictor of major bleeding. We provide the state-of-the-art of assessing and managing bleeding risk in patients with acute VTE and highlight a practical approach for daily practice illustrated by 2 case scenarios.
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Pastori D, Ettorre E, Lip GYH, Sciacqua A, Perticone F, Melillo F, Godino C, Marcucci R, Berteotti M, Violi F, Pignatelli P, Saliola M, Menichelli D, Casciaro MA, Menafra V. Association of different oral anticoagulants use with renal function worsening in patients with atrial fibrillation: A multicentre cohort study. Br J Clin Pharmacol 2020; 86:2455-2463. [PMID: 32384178 DOI: 10.1111/bcp.14350] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS To investigate the decline of estimated glomerular filtration rate (eGFR) in patients with atrial fibrillation (AF) treated with vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs). METHODS Multicentre prospective cohort study including 1667 patients with nonvalvular AF. The eGFR was assessed by the CKD-EPI formula at baseline and during follow-up. The primary endpoint of the study was the median annual decline of eGFR according to VKA (n = 743) or NOAC (n = 924) use. As secondary endpoints, we analysed the transition to eGFR <50 mL/min/1.73 m2 and the eGFR class worsening. RESULTS Median age was 73.7 ± 9.1 years and 43.3% were women. VKA-treated patients showed an eGFR decline of -2.11 (interquartile range [IQR] -5.68/-0.62), which was -0.27 (IQR -9.00/4.54, P < 0.001 vs VKAs), -1.21 (IQR -9.98/4.02, P = 0.004 vs VKAs) and -1.32 (IQR -8.70/3.99, P = 0.003 vs VKAs) in patients on dabigatran, rivaroxaban and apixaban, respectively. Transition to eGFR <50 mL/min/1.73 m2 was lower in dabigatran- and apixaban-treated patients: odds ratio (OR) 0.492, 95% confidence interval (CI) 0.298-0.813, P = 0.006 and OR 0.449, 95% CI 0.276-0.728, P = 0.001, respectively. A lower rate of eGFR class worsening was found in all groups of NOACs compared to VKAs. No difference between full and reduced dose of NOAC was found. Subgroup analysis showed that the association between NOAC and eGFR changes was markedly reduced in diabetic patients. CONCLUSION Patients prescribed NOACs showed a lower decline of renal function compared to those prescribed VKAs. This effect was partially lost in patients with diabetes.
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Affiliation(s)
- Daniele Pastori
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Evaristo Ettorre
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Angela Sciacqua
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Italy
| | - Francesco Perticone
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Italy
| | - Francesco Melillo
- Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy
| | - Cosmo Godino
- Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Martina Berteotti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Violi
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Mirella Saliola
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Danilo Menichelli
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco Antonio Casciaro
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Vito Menafra
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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Wilson LE, Luo X, Li X, Mardekian J, Garcia Reeves AB, Skinner A. Clinical outcomes and treatment patterns among Medicare patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease. PLoS One 2019; 14:e0225052. [PMID: 31725743 PMCID: PMC6855694 DOI: 10.1371/journal.pone.0225052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 10/28/2019] [Indexed: 01/18/2023] Open
Abstract
Background Patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease (CKD) have increased risk of adverse outcomes. This study evaluated treatment with oral anticoagulants and outcomes in elderly NVAF patients with CKD. Methods Retrospective observational cohort study of US Medicare fee-for-service patients aged ≥66 years with comorbid CKD (advanced: Stage 4 and higher; less advanced: Stages 1–3) and a new NVAF diagnoses from 2011–2013. All-cause mortality, stroke, major bleeding, and myocardial infarction rates were estimated for 1 year post-NVAF diagnosis. Associations between CKD stage and outcomes were evaluated with multivariate-adjusted Cox regression. We assessed oral anticoagulant (OAC) receipt within 90 days post-NVAF diagnosis and associations between OAC receipt and outcomes. Results There were 198,380 eligible patients (79,681 with advanced CKD). After adjustment for age, gender, and comorbidities, advanced CKD was associated with increased mortality (Stage 5 HR 1.47; 95% CI 1.42–1.52), MI (HR 1.48; 95% CI 1.33–1.64), stroke (HR 1.23; 95% CI 1.11–1.37) and major bleed (HR 1.44; 95% CI 1.36–1.53) risks. Among Medicare Part D enrollees who survived ≥90 days post-NVAF diagnosis, 65–71% received no OACs in the first 90 days. Those receiving warfarin (HR 0.73; 95% CI 0.71–0.75) or DOACs (HR 0.52; 95% CI 0.49–0.56) within the first 90 days had reduced mortality in the period 90 days to 1 year following NVAF diagnosis compared to those without. Conclusion Elderly NVAF patients with advanced CKD (Stage 4 or higher) had higher mortality risks and serious clinical outcomes than those with less advanced CKD (Stage 1–3). OAC use was low across all CKD stages, but was associated with a lower mortality risk than no OAC use in the first year post-NVAF diagnosis.
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Affiliation(s)
- Lauren E. Wilson
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, United States of America
- * E-mail:
| | - Xuemei Luo
- Pfizer, Inc., New York City, NY, United States of America
| | - Xiaoyan Li
- Bristol Myers-Squibb Company, New York City, NY, United States of America
| | - Jack Mardekian
- Pfizer, Inc., New York City, NY, United States of America
| | - Alessandra B. Garcia Reeves
- Bristol Myers-Squibb Company, New York City, NY, United States of America
- University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Asheley Skinner
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, United States of America
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Ahmed SB, Dumanski SM. Why Do Patients With Well-Controlled Vascular Risk Factors Develop Progressive Chronic Kidney Disease? Can J Cardiol 2019; 35:1170-1180. [DOI: 10.1016/j.cjca.2019.06.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/07/2019] [Accepted: 06/14/2019] [Indexed: 01/17/2023] Open
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Importance of Risk Reassessment in Patients With Atrial Fibrillation in Guidelines: Assessing Risk as a Dynamic Process. Can J Cardiol 2019; 35:611-618. [DOI: 10.1016/j.cjca.2019.01.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 02/07/2023] Open
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