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Lucà F, Oliva F, Giubilato S, Abrignani MG, Rao CM, Cornara S, Caretta G, Di Fusco SA, Ceravolo R, Parrini I, Murrone A, Geraci G, Riccio C, Gelsomino S, Colivicchi F, Grimaldi M, Gulizia MM. Exploring the Perioperative Use of DOACs, off the Beaten Track. J Clin Med 2024; 13:3076. [PMID: 38892787 PMCID: PMC11172442 DOI: 10.3390/jcm13113076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
A notable increase in direct oral anticoagulant (DOAC) use has been observed in the last decade. This trend has surpassed the prescription of vitamin K antagonists (VKAs) due to the absence of the need for regular laboratory monitoring and the more favorable characteristics in terms of efficacy and safety. However, it is very common that patients on DOACs need an interventional or surgical procedure, requiring a careful evaluation and a challenging approach. Therefore, perioperative anticoagulation management of patients on DOACs represents a growing concern for clinicians. Indeed, while several surgical interventions require temporary discontinuation of DOACs, other procedures that involve a lower risk of bleeding can be conducted, maintaining a minimal or uninterrupted DOAC strategy. Therefore, a comprehensive evaluation of patient characteristics, including age, susceptibility to stroke, previous bleeding complications, concurrent medications, renal and hepatic function, and other factors, in addition to surgical considerations, is mandatory to establish the optimal discontinuation and resumption timing of DOACs. A multidisciplinary approach is required for managing perioperative anticoagulation in order to establish how to face these circumstances. This narrative review aims to provide physicians with a practical guide for DOAC perioperative management, addressing the most controversial issues.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89124 Reggio Calabria, Italy;
| | - Fabrizio Oliva
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy;
| | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy;
| | | | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89124 Reggio Calabria, Italy;
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy
| | - Giorgio Caretta
- Sant’Andrea Hospital, ASL 5 Regione Liguria, 19124 La Spezia, Italy
| | | | - Roberto Ceravolo
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy;
| | - Iris Parrini
- Cardiology Department, Mauriziano Hospital, 10128 Torino, Italy;
| | - Adriano Murrone
- Cardiology Unit, Città di Castello Hospital, 06012 Città di Castello, Italy;
| | - Giovanna Geraci
- Cardiology Department, Sant’Antonio Abate Hospital, ASP Trapani, 91100 Erice, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 95122 Caserta, Italy;
| | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands;
| | - Furio Colivicchi
- Cardiology Unit, Giovanni Paolo II Hospital, 97100 Lamezia, Italy; (S.A.D.F.); (F.C.)
| | - Massimo Grimaldi
- Cardiology Department, F. Miulli Hospital, Acquaviva delle Fonti, 70021 Bari, Italy;
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Papakonstantinou PE, Kalogera V, Charitos D, Polyzos D, Benia D, Batsouli A, Lampropoulos K, Xydonas S, Gupta D, Lip GYH. When anticoagulation management in atrial fibrillation becomes difficult: Focus on chronic kidney disease, coagulation disorders, and cancer. Blood Rev 2024; 65:101171. [PMID: 38310007 DOI: 10.1016/j.blre.2024.101171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 02/05/2024]
Abstract
Anticoagulation therapy (AT) is fundamental in atrial fibrillation (AF) treatment but poses challenges in implementation, especially in AF populations with elevated thromboembolic and bleeding risks. Current guidelines emphasize the need to estimate and balance thrombosis and bleeding risks for all potential candidates of antithrombotic therapy. However, administering oral AT raises concerns in specific populations, such as those with chronic kidney disease (CKD), coagulation disorders, and cancer due to lack of robust data. These groups, excluded from large direct oral anticoagulants trials, rely on observational studies, prompting physicians to adopt individualized management strategies based on case-specific evaluations. The scarcity of evidence and specific guidelines underline the need for a tailored approach, emphasizing regular reassessment of risk factors and anticoagulation drug doses. This narrative review aims to summarize evidence and recommendations for challenging AF clinical scenarios, particularly in the long-term management of AT for patients with CKD, coagulation disorders, and cancer.
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Affiliation(s)
| | - Vasiliki Kalogera
- Third Cardiology Department, School of Medicine, National and Kapodistrian University of Athens, "Sotiria" Chest Hospital, Mesogeion Ave 152, 11527 Athens, Greece
| | - Dimitrios Charitos
- First Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitrios Polyzos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitra Benia
- Cardiology Department, General Hospital-Health Center of Kithira, Aroniadika, 80200 Kithira Island, Greece
| | - Athina Batsouli
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Konstantinos Lampropoulos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece; School of Medicine, European University of Cyprus, Diogenous 6, 2404 Egkomi, Cyprus
| | - Sotirios Xydonas
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, L14 3PE Liverpool, United Kingdom.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Thomas Dr., L14 3PE Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Selma Lagerløfs Vej 249, 9260 Gistrup, Aalborg, Denmark.
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Gwechenberger M, Barón-Esquivias G, de Vries TA, Siller-Matula JM, Manu MC, Souza JA, Wienerroither S, Pecen L, de Groot JR, De Caterina R, Kirchhof P. Incidence and Predictors of Worsening Renal Function in Edoxaban-Treated Atrial Fibrillation Patients Within ETNA-AF-Europe Registry. JACC. ADVANCES 2024; 3:100880. [PMID: 38939675 PMCID: PMC11198551 DOI: 10.1016/j.jacadv.2024.100880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/27/2023] [Accepted: 12/20/2023] [Indexed: 06/29/2024]
Abstract
Background Managing patients with atrial fibrillation (AF) and worsening renal function (WRF) remains a clinical challenge due to the need of dose adjustment of non-vitamin K antagonist oral anticoagulants. Objectives To determine the incidence of WRF in patients with AF treated with edoxaban, the association of WRF with clinical outcomes, and predictors of WRF and clinical outcomes in these patients. Methods This is a subanalysis of the Edoxaban Treatment in routiNe clinical prActice for patients with non-valvular Atrial Fibrillation in Europe study (NCT02944019), an observational study of edoxaban-treated patients with AF. WRF was defined as a ≥25% reduction in creatinine clearance between baseline and 2 years. Results Of the 9,054 patients included (69% of the total 13,133 enrolled), most did not experience WRF (90.3%) during the first 2 years of follow-up. WRF occurred in 9.7% of patients. Patients with WRF had significantly higher rates of all-cause death (3.88%/y vs 1.88%/y; P < 0.0001), cardiovascular death (2.09%/y vs 0.92%/y; P < 0.0001), and major bleeding (1.51%/y vs 0.98%/y; P = 0.0463) compared with those without WRF. Rates of intracranial hemorrhage (0.18%/y vs 0.18%/y) and of any stroke/systemic embolic events were low (0.90%/y vs 0.69%/y; P = 0.3161) in both subgroups. The strongest predictors of WRF were a high CHA2DS2-VASc score, high baseline creatinine clearance, low body weight, and older age. Most predictors of WRF were also predictors of clinical outcomes. Conclusions WRF occurred in approximately 10% of edoxaban-treated AF patients. Rates of death and major bleeding were significantly higher in patients with WRF than without. Stroke events were low in both subgroups.
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Affiliation(s)
| | | | - Tim A.C. de Vries
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, the Netherlands
- Department of Cardiology, Rijnstate Hospital, Arnhem, the Netherlands
| | | | | | | | | | - Ladislav Pecen
- Institute of Computer Science of the Czech Academy of Sciences, Prague, Czech Republic
- Department of Immunochemistry Diagnostics, University Hospital Pilsen, Pilsen, Czech Republic
| | - Joris R. de Groot
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, the Netherlands
| | - Raffaele De Caterina
- Cardiology Division, University of Pisa, Pisa, Italy
- Fondazione VillaSerena per la Ricerca, Pescara, Italy
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Sciences (DZHK) Partner Site Hamburg/Kiel/Lübeck, Hamburg/Kiel/Lübeck, Germany
| | - ETNA-AF-Europe Investigators
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
- Virgen del Rocio University Hospital, University of Seville, Seville, Spain
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, the Netherlands
- Department of Cardiology, Rijnstate Hospital, Arnhem, the Netherlands
- Daiichi Sankyo Europe GmbH, Munich, Germany
- Daiichi Sankyo Austria GmbH, Vienna, Austria
- Institute of Computer Science of the Czech Academy of Sciences, Prague, Czech Republic
- Department of Immunochemistry Diagnostics, University Hospital Pilsen, Pilsen, Czech Republic
- Cardiology Division, University of Pisa, Pisa, Italy
- Fondazione VillaSerena per la Ricerca, Pescara, Italy
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Sciences (DZHK) Partner Site Hamburg/Kiel/Lübeck, Hamburg/Kiel/Lübeck, Germany
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Westreich R, Tsaban G, Barrett O, Kezerle L, Tsadok MA, Akriv A, Bachrach A, Leventer-Roberts M, Senderey AB, Haim M. Estimated glomerular filtration rate and the risk of stroke in individuals with diabetes mellitus and atrial fibrillation insight from a large contemporary population study. J Thromb Thrombolysis 2024; 57:322-329. [PMID: 37945939 DOI: 10.1007/s11239-023-02913-8] [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] [Accepted: 10/22/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) is associated with increased risk of embolic complications in non-valvular atrial fibrillation (NVAF). Impaired renal function (IRF) increases the risk of stroke as well, but this finding is not consistent among all studies. Our aim was to assess the incidence rates and risk of ischemic stroke and mortality by baseline Estimated Glomerular Filtration Rate (eGFR) levels Among individuals with AF and DM. METHODS A prospective, historical cohort study using the Clalit Health Services electronic medical records database. Among patients with AF and DM, we compared three groups according to eGFR levels: eGFR ≥ 60, between 30 and 60, and ≤ 30 (mL/min/1.73m2). RESULTS A total of 17,567 cases were included in the final analysis; of them, 11,013 (62.7%) had eGFR ≥ 60, 4930 (28%) had eGFR between 30 and 60, and 1624 (9.24%) with eGFR ≤ 30. The incidence of stroke per 100 person-years in the three study groups was: 1.88, 2.69, and 3.34, respectively (p < 0.001). IRF was associated with increased risk of stroke in univariate analysis, but not after multivariate adjustment (Adjusted Hazard Ratio (AHR) 0.96 {95%CI; 0.74-1.25} for eGFR 30-60 and 0.96 {95%CI; 0.60-1.55} for eGFR ≤ 30). Mortality per 100 person-years was 10.78, 21.49, and 41.55, respectively (p < 0.001). IRF was associated with increased mortality risk in univariate analysis, as well as in multivariate analysis (AHR 1.08 {95%CI; 0.98-1.18} for eGFR 30-60, and 1.59 {95%CI; 1.37-1.85} for eGFR ≤ 30. CONCLUSION In patients with NVAF and DM, IRF was not associated with an increased risk of stroke, but severe IRF (eGFR ≤ 30) was associated with increased mortality risk.
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Affiliation(s)
- Roi Westreich
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel.
| | - Gal Tsaban
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel
| | - Orit Barrett
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel
| | - Louise Kezerle
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel
| | - Meytal Avgil Tsadok
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Amichay Akriv
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Asaf Bachrach
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Maya Leventer-Roberts
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Adi Berliner Senderey
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Moti Haim
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel
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5
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Barnes GD, Wright Nunes JA. Stroke prevention in atrial fibrillation with chronic kidney disease: a delicate balance of efficacy and safety considerations. Res Pract Thromb Haemost 2024; 8:102370. [PMID: 38666063 PMCID: PMC11043628 DOI: 10.1016/j.rpth.2024.102370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 03/04/2024] [Indexed: 04/28/2024] Open
Affiliation(s)
- Geoffrey D. Barnes
- University of Michigan Frankel Cardiovascular Center, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Julie A. Wright Nunes
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Tsai CT, Liao JN, Chan YH, Kuo L, Liu CM, Lip GY, Chao TF. Which dose of apixaban is suitable for Asian patients with atrial fibrillation who have a serum creatinine < 1.5 mg/dL but an estimated glomerular filtration rate < 50 mL/min? IJC HEART & VASCULATURE 2024; 50:101333. [PMID: 38419610 PMCID: PMC10899727 DOI: 10.1016/j.ijcha.2023.101333] [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: 09/25/2023] [Revised: 12/03/2023] [Accepted: 12/19/2023] [Indexed: 03/02/2024]
Abstract
Introduction Reduced-dose (Low-dose [LD]) apixaban is recommended in patients with atrial fibrillation (AF) who fulfill 2 of 3 criteria: age ≥ 80 years, body weight ≤ 60 kg, and a serum creatinine (sCr) ≥ 1.5 mg/dl. However, the suitable (appropriate) dose for Asian patients who have a sCr < 1.5 mg/dl but an estimated glomerular filtration rate (eGFR) < 50 mL/min is unknown. Methods This is a retrospective study using the Chang Gung Memorial hospital medical database in Taiwan. A total of 13,508 AF patients receiving oral anticoagulants (OACs) from 2012 to 2018 were reviewed and 1595 patients with a sCr < 1.5 mg/dL and an eGFR < 50 mL/min who met 1 criterion of dose reduction of apixaban other than sCr (that is, age ≥ 80 years or body weight < 60 kg) were identified. Clinical outcomes were compared between LD and SD apixaban versus warfarin. Results Their OACs use was as follows: 343 receiving apixaban (128 patients on standard dose [SD] and 215 on LD), 174 receiving warfarin, and 1078 on other NOACs. Patients with an eGFR < 50 mL/min had higher risk of mortality (adjusted hazard ratio [aHR], 1.264; 95 % confidence interval [CI], 1.086-1.472) and composite endpoint of 'ischemic stroke/systemic embolism (IS/SE) or major bleeding or mortality (aHR, 1.202; 95 % CI, 1.056-1.370) compared to those with an eGFR ≥ 50 mL/min whereas the risk of IS/SE and major bleeding were similar. LD apixaban was associated with lower risk of composite endpoint of IS/SE or major bleeding (aHR, 0.567; 95 % CI, 0.331 - 0.972), mortality (aHR, 0.336; 95 % CI, 0.138 - 0.815), and 'IS/SE or major bleeding or mortality (aHR, 0.551; 95 % CI, 0343 - 0.886) compared to warfarin while the risk was comparable between SD apixaban and warfarin (aHR, 0.745; 95 % CI, 0.402 - 1.378; aHR, 0.407; 95 % CI, 0.145 - 1.143; aHR, 0.619; 95 % CI, 0.354 - 1.084, respectively). Conclusion In patients with sCr < 1.5 mg/dL and eGFR < 50 mL/min, SD and LD apixaban were comparable in the prevention of IS/SE, but LD apixaban was superior in reducing the composite endpoint of 'IS/SE or major bleeding or mortality'. Therefore, LD apixaban might be a preferred dose for this population.
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Affiliation(s)
- Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung 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 Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Ling Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Min Liu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, 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 & Chest Hospital, Liverpool, United Kingdom; and Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - 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 Chiao Tung University, Taipei, Taiwan
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Kreutz R, Deray G, Floege J, Gwechenberger M, Hahn K, Luft AR, Persson P, Axthelm C, Beer JH, Bergler-Klein J, Lellouche N, Taggeselle J, Coleman CI, Beyer-Westendorf J. Rivaroxaban vs Vitamin K Antagonist in Patients With Atrial Fibrillation and Advanced Chronic Kidney Disease. JACC. ADVANCES 2024; 3:100813. [PMID: 38939389 PMCID: PMC11198259 DOI: 10.1016/j.jacadv.2023.100813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/24/2023] [Accepted: 10/23/2023] [Indexed: 06/29/2024]
Abstract
Background Treatment with vitamin K antagonists (VKAs) has been linked to worsening of kidney function in patients with atrial fibrillation (AF). Objectives XARENO (Factor XA-inhibition in RENal patients with non-valvular atrial fibrillation Observational registry; NCT02663076) is a prospective observational study comparing adverse kidney outcomes in patients with AF and advanced chronic kidney disease receiving rivaroxaban or VKA. Methods Patients with AF and an estimated glomerular filtration rate (eGFR) of 15 to 49 mL/min/1.73 m2 were included. Blinded adjudicated outcome analysis evaluated adverse kidney outcomes (a composite of eGFR decline to <15 mL/min/1.73 m2, need for chronic kidney replacement therapy, or development of acute kidney injury). A composite net clinical benefit outcome (stroke or systemic embolism, major bleeding, myocardial infarction, acute coronary syndrome, or cardiovascular death) was also analyzed. HRs with 95% CIs were calculated using propensity score overlap weighting Cox regression. Results There were 1,455 patients (764 rivaroxaban; 691 VKA; mean age 78 years; 44% females). The mean eGFR was 37.1 ± 9.0 in those receiving rivaroxaban and 36.4 ± 10.1 mL/min/1.73 m2 in those receiving VKA. After a median follow-up of 2.1 years, rivaroxaban was associated with less adverse kidney outcomes (HR: 0.62; 95% CI: 0.43-0.88) and all-cause death (HR: 0.76, 95% CI: 0.59-0.98). No significant differences were observed in net clinical benefit. Conclusions In patients with AF and advanced chronic kidney disease, those receiving rivaroxaban had less adverse kidney events and lower all-cause mortality compared to those receiving VKA, supporting the use of rivaroxaban in this high-risk group of patients.
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Affiliation(s)
- Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Gilbert Deray
- Department of Nephrology, Pitié-Salpêtrière Hospital, Paris, France
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Marianne Gwechenberger
- Division of Cardiology, University Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Kai Hahn
- Nephrologische Praxis, Dortmund, Germany
| | - Andreas R. Luft
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Switzerland
- Cereneo, Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Pontus Persson
- Institut für Vegetative Physiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Juerg Hans Beer
- Department Innere Medizin, Kantonsspital Baden, Baden, Switzerland
- Center of Molecular Cardiology, University of Zürich, Zürich, Switzerland
| | - Jutta Bergler-Klein
- Division of Cardiology, University Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Nicolas Lellouche
- Service de Cardiologie 1, Centre Hospitalier Universitaire Henri Mondor, Créteil, France
| | | | - Craig I. Coleman
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Evidence-Based Practice Center, Hartford Hospital, Hartford, Connecticut, USA
| | - Jan Beyer-Westendorf
- Department of Medicine I, Division Thrombosis & Hemostasis, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
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Shantsila E, Choi EK, Lane DA, Joung B, Lip GY. Atrial fibrillation: comorbidities, lifestyle, and patient factors. THE LANCET REGIONAL HEALTH. EUROPE 2024; 37:100784. [PMID: 38362547 PMCID: PMC10866737 DOI: 10.1016/j.lanepe.2023.100784] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/25/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
Modern anticoagulation therapy has dramatically reduced the risk of stroke and systemic thromboembolism in people with atrial fibrillation (AF). However, AF still impairs quality of life, increases the risk of stroke and heart failure, and is linked to cognitive impairment. There is also a recognition of the residual risk of thromboembolic complications despite anticoagulation. Hence, AF management is evolving towards a more comprehensive understanding of risk factors predisposing to the development of this arrhythmia, its' complications and interventions to mitigate the risk. This review summarises the recent advances in understanding of risk factors for incident AF and managing these risk factors. It includes a discussion of lifestyle, somatic, psychological, and socioeconomic risk factors. The available data call for a practice shift towards a more individualised approach considering an increasingly broader range of health and patient factors contributing to AF-related health burden. The review highlights the needs of people living with co-morbidities (especially with multimorbidity), polypharmacy and the role of the changing population demographics affecting the European region and globally.
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Affiliation(s)
- Eduard Shantsila
- Department of Primary Care and Mental Health, University of Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Brownlow Group GP Practice, Liverpool, United Kingdom
| | - Eue-Keun Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Republic of Korea
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, University of Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Denmark
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9
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Jones A, Swan D, Lisman T, Barnes GD, Thachil J. Anticoagulation in chronic kidney disease: current status and future perspectives. J Thromb Haemost 2024; 22:323-336. [PMID: 37778512 DOI: 10.1016/j.jtha.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/14/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
Chronic kidney disease (CKD) is being diagnosed increasingly worldwide. It is often identified in individuals with comorbidities, which may increase the already heightened risk of thrombosis and hemorrhage associated with CKD. Oral anticoagulation is an effective means of reducing rates of ischemic stroke and systemic embolism in patients with atrial fibrillation and minimizes the morbidity and mortality caused by venous thromboembolic disease. Despite the proven benefits in the majority of patients, these have not been so clearly realized in patients with CKD due to the precarious balance between bleeding and thromboembolic complications. In this review, the current status of anticoagulant utilization in CKD is examined, and some practical recommendations are put forward to assist in the decision-making process of safely anticoagulating patients with CKD diagnosed with atrial fibrillation and venous thromboembolism.
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Affiliation(s)
- Alfred Jones
- Department of Haematology, Beaumont Hospital, Dublin, Ireland
| | - Dawn Swan
- Department of Haematology, Beaumont Hospital, Dublin, Ireland.
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Oxford Road, Manchester, United Kingdom
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10
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Vitolo M, Gerra L, Boriani G. Oral anticoagulants in patients with atrial fibrillation and end-stage renal disease: Walking the tightrope between thromboembolic and bleeding risk. Eur J Intern Med 2024; 119:39-41. [PMID: 37925354 DOI: 10.1016/j.ejim.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023]
Affiliation(s)
- Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Luigi Gerra
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.
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11
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Tsiachris D, Papakonstantinou PE, Doundoulakis I, Tsioufis P, Botis M, Dimitriadis K, Leontsinis I, Kordalis A, Antoniou CK, Mantzouranis E, Iliakis P, Vlachakis PK, Gatzoulis KA, Tsioufis K. Anticoagulation Status and Left Atrial Appendage Occlusion Indications in Hospitalized Cardiology Patients with Atrial Fibrillation: A Hellenic Cardiorenal Morbidity Snapshot (HECMOS) Sub-Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1881. [PMID: 37893599 PMCID: PMC10608124 DOI: 10.3390/medicina59101881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 09/21/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: The proper use of oral anticoagulants is crucial in the management of non-valvular atrial fibrillation (AF) patients. Left atrial appendage closure (LAAC) may be considered for stroke prevention in patients with AF and contraindications for long-term anticoagulant treatment. We aimed to assess anticoagulation status and LAAC indications in patients with AF from the HECMOS (Hellenic Cardiorenal Morbidity Snapshot) survey. Materials and Methods: The HECMOS was a nationwide snapshot survey of cardiorenal morbidity in hospitalized cardiology patients. HECMOS used an electronic platform to collect demographic and clinically relevant information from all patients hospitalized on 3 March 2022 in 55 different cardiology departments. In this substudy, we included patients with known AF without mechanical prosthetic valves or moderate-to-severe mitral valve stenosis. Patients with prior stroke, previous major bleeding, poor adherence to anticoagulants, and end-stage renal disease were considered candidates for LAAC. Results: Two hundred fifty-six patients (mean age 76.6 ± 11.7, 148 males) were included in our analysis. Most of them (n = 159; 62%) suffered from persistent AF. The mean CHA2DS2-VASc score was 4.28 ± 1.7, while the mean HAS-BLED score was 1.47 ± 0.9. Three out of three patients with a a CHA2DS2-VASc score of 0 or 1 (female) were inappropriately anticoagulated. Sixteen out of eighteen patients with a CHA2DS2-VASc score 1 or 2 (if female) received anticoagulants. Thirty-one out of two hundred thirty-five patients with a CHA2DS2-VASc score > 1 or 2 (if female) were inappropriately not anticoagulated. Relative indications for LAAC were present in 68 patients with NVAF (63 had only one risk factor and 5 had two concurrent risk factors). In detail, 36 had a prior stroke, 17 patients had a history of major bleeding, 15 patients reported poor or no adherence to the anticoagulant therapy and 5 had an eGFR value < 15 mL/min/1.73 m2 for a total of 73 risk factors. Moreover, 33 had a HAS-BLED score ≥ 3. No LAAC treatment was recorded. Conclusions: Anticoagulation status was nearly optimal in a high-thromboembolic-risk population of cardiology patients who were mainly treated using NOACs. One out of four AF patients should be screened for LAAC.
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Affiliation(s)
- Dimitris Tsiachris
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
- Athens Heart Center, Athens Medical Center, 15125 Athens, Greece
| | - Panteleimon E. Papakonstantinou
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Ioannis Doundoulakis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Panagiotis Tsioufis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Michail Botis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Kyriakos Dimitriadis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Ioannis Leontsinis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Athanasios Kordalis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Christos-Konstantinos Antoniou
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
- Athens Heart Center, Athens Medical Center, 15125 Athens, Greece
| | - Emmanouil Mantzouranis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Panagiotis Iliakis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Panayotis K. Vlachakis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Konstantinos A. Gatzoulis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
| | - Konstantinos Tsioufis
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” Hospital, 11527 Athens, Greece; (P.E.P.); (I.D.); (P.T.); (M.B.); (K.D.); (I.L.); (A.K.); (C.-K.A.); (E.M.); (P.I.); (P.K.V.); (K.A.G.); (K.T.)
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12
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Abuelazm M, Mahmoud A, Ali S, Gamal M, Elmezayen A, A. Elzeftawy M, Abdelazeem B. The efficacy and safety of direct factor Xa inhibitors versus vitamin K antagonists for atrial fibrillation in patients on hemodialysis: a meta-analysis of randomized controlled trials. Proc AMIA Symp 2023; 36:736-743. [PMID: 37829214 PMCID: PMC10566404 DOI: 10.1080/08998280.2023.2247958] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 08/03/2023] [Indexed: 10/14/2023] Open
Abstract
Background Direct factor Xa inhibitors have been extensively prescribed for multiple indications; however, hemodialysis patients have been excluded from most of the randomized controlled trials (RCTs) of direct factor Xa inhibitors. Therefore, the efficacy and safety of direct factor Xa inhibitors versus vitamin K antagonists (VKAs) in hemodialysis patients is uncertain. Methods A systematic review and meta-analysis of RCTs was conducted by systematically searching PubMed, EMBASE, Web of Science, SCOPUS, and Cochrane through November 25, 2022. We used the fixed-effect model to pool the risk ratio (RR) with a 95% confidence interval (CI). RevMan v5.4 software was used to pool dichotomous outcomes using RR and continuous outcomes using mean difference presented with the corresponding CI. Results Three RCTs with a total of 341 patients were included in our analysis. There was no difference between direct factor Xa inhibitors and VKAs regarding all-cause mortality (RR, 0.99; 95% CI [0.76, 1.30]; P = 0.96), cardiovascular mortality (RR, 1.35; 95% CI [0.71, 2.60]; P = 0.36), noncardiovascular mortality (RR, 0.75; 95% CI [0.53, 1.05]; P = 0.09), sudden mortality (RR, 1.33; 95% CI [0.53, 3.33]; P = 0.54), any cerebrovascular event (RR, 0.52; 95% CI [0.21, 1.29]; P = 0.16), ischemic stroke (RR, 0.51; 95% CI [0.19, 1.37]; P = 0.18), and hemorrhagic stroke (RR, 0.61; 95% CI [0.10, 3.70]; P = 0.59). Conclusion In patients with atrial fibrillation who are on hemodialysis, direct factor Xa inhibitors and VKAs were similar in terms of efficacy and safety outcomes. However, evidence is still sparse, warranting dedicated RCTs.
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Affiliation(s)
| | | | - Shafaqat Ali
- Department of Internal Medicine, Louisiana State University, Shreveport, Louisiana, USA
| | | | - Ahmed Elmezayen
- Department of Cardiothoracic Surgery, Manchester Foundation Trust, Manchester University, Manchester, UK
| | | | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, Morgantown, West Virginia, USA
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Escobar-Cervantes C, Reino AP, Díez-Villanueva P, Facila L, Freixa-Pamias R, Valle A, Almendro-Delia M, Bonanad C, Vivas D, Suarez C. Should atrial fibrillation be considered a vascular disease? The need for a comprehensive vascular approach. Expert Rev Cardiovasc Ther 2023; 21:779-790. [PMID: 37874226 DOI: 10.1080/14779072.2023.2272652] [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: 09/06/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) cannot be considered an isolated disease. Patients with AF should be managed using a comprehensive approach that is not limited to stroke prevention. AREAS COVERED In this manuscript, the potential role of AF as a vascular disease that is managed as part of a holistic approach was reviewed. EXPERT OPINION The residual risk of stroke in patients with AF reaches 1-2% annually, despite appropriate anticoagulation therapy. Additionally, patients with AF may develop cognitive impairment through stroke-independent pathways. Furthermore, patients with AF may have a higher risk of developing atherosclerotic vascular disease in various vascular beds and chronic kidney disease; conversely, patients with atherosclerotic disease may have an increased risk of developing AF. AF should be considered a truly systemic vascular disease, since it brings together several hemodynamic and systemic changes, including inflammation, oxidative stress, activation of the renin-angiotensin-aldosterone and sympathetic systems, as well as a prothrombotic state and endothelial dysfunction. In this regard, patients with AF should be treated based on a holistic approach that is not limited to oral anticoagulation but includes complete vascular protection.
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Affiliation(s)
| | - Antonio Pose Reino
- Hypertension and vascular risk unit, Internal Medicine Service, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | | | - Lorenzo Facila
- Cardiology Department, Hospital General de Valencia, Universitat de Valencia, Valencia,Spain
| | | | - Alfonso Valle
- Cardiology department, Hospital de Denia, Alicante, Spain
| | - Manuel Almendro-Delia
- Intensive Cardiovascular Care Unit, Cardiovascular Clinical Trials & Translational Research Unit, Cardiology and Cardiovascular Surgery Division, Virgen Macarena University Hospital, Sevilla, Spain
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Medicine Department, Faculty of Medicine of the University of Valencia, Valencia, Spain
- Cardiology Section, Health Research Institute of the Valencia Clinical Hospital (INCLIVA), Valencia, Spain
| | - David Vivas
- Cardiology Department, Instituto Cardiovascular Hospital Clínico San Carlos, Madrid, Spain
| | - Carmen Suarez
- Internal Medicine Service, Hospital Universitario de La Princesa, Madrid, Spain
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Simic J, Mihajlovic M, Zec N, Kovacevic V, Marinkovic M, Mujovic N, Potpara T. The impact of anticoagulation therapy on kidney function in patients with atrial fibrillation and chronic kidney disease. Expert Rev Cardiovasc Ther 2023; 21:937-945. [PMID: 37842943 DOI: 10.1080/14779072.2023.2270909] [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: 07/27/2023] [Accepted: 10/11/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) and chronic kidney disease (CKD) are closely related. These diseases share common risk factors and are associated with increased risk of thromboembolic events. Choosing the appropriate oral anticoagulant therapy (OAC) in patients with AF and CKD is challenging. Deterioration of renal function is common in patients with AF treated with OACs, although not all OACs affect the kidneys equally. AREAS COVERED In this review, we aim to summarize the current knowledge of the prevention of thromboembolic events in patients with AF and CKD, focusing on the impact of specific OAC agents on renal function. EXPERT OPINION Consideration of OAC use is mandatory in patients with AF and CKD who are at increased risk of stroke or systemic embolism. Available evidence suggests that the use of non-vitamin K antagonist oral anticoagulants (NOACs) is associated with slower deterioration of renal function in comparison to Vitamin K antagonists (VKAs). Hence, a NOAC should be used in preference to VKAs in all NOAC-eligible patients with AF and CKD. Regarding patients with end-stage renal dysfunction and those on dialysis or renal replacement therapy, the use of NOAC should be considered in line with locally relevant formal recommendations.
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Affiliation(s)
- Jelena Simic
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Nevena Zec
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vladan Kovacevic
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Milan Marinkovic
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nebojsa Mujovic
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Tatjana Potpara
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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15
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Gosselin L, Vilcu AM, Souty C, Steichen O, Launay T, Conte C, Saint-Salvi B, Turbelin C, Sarazin M, Blanchon T, Hanslik T, Lapeyre-Mestre M, Rossignol L. Prevalence and bleeding risk associated with the concomitant use of direct oral anticoagulants and antiarrhythmic drugs in patients with atrial fibrillation, based on the French healthcare insurance database. Eur J Clin Pharmacol 2023:10.1007/s00228-023-03501-8. [PMID: 37184597 DOI: 10.1007/s00228-023-03501-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/26/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE Pharmacokinetic interactions exist between apixaban or rivaroxaban, and CYP3A4 and P-glycoprotein inhibitors such as amiodarone, verapamil and diltiazem. We aimed to estimate the prevalence of exposure to this drug-drug association (DDA) and to assess the bleeding risk associated in patients with atrial fibrillation (AF). METHODS We conducted a cohort study using a representative 1/97th sample of the French healthcare insurance database between 2014 and 2019. Patients with AF receiving apixaban or rivaroxaban were included and followed-up until hospitalization for bleeding, death, discontinuation of apixaban or rivaroxaban, exposure to strong CYP3A4 inhibitor, or until December 31st 2019, whichever came first. Primary outcome was hospitalization for bleeding registered as primary diagnosis. The association between the exposure to the DDA and hospitalization for bleeding was evaluated as a time-dependent variable in Cox model. RESULTS Between 2014 and 2019, the AF population under apixaban or rivaroxaban represented 10,392 patients. During the study period, the annual average prevalence of DDA exposure in this population was 38.9%. Among the 10,392 patients, 223 (2.1%) were hospitalized for bleeding, of which 75 (33.6%) received the association and 148 (66.4%) received apixaban or rivaroxaban alone. There was no association between DDA exposure and risk of hospitalization for bleeding (aHR = 1.19, [95% CI: 0.90, 1.58]). Age (HR 1.03 [1.02, 1.05]) and male gender (HR 1.72 [1.28, 2.30]) were associated with an increased risk of hospitalization for bleeding. CONCLUSION Exposure to antiarrhythmic drugs was not associated with an increased risk of hospitalization for bleeding in patients with AF under rivaroxaban or apixaban.
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Affiliation(s)
- Laëtitia Gosselin
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France.
- Département de Médecine Générale, Université Paris Cité, Paris, France.
| | - Ana-Maria Vilcu
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
| | - Cécile Souty
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
| | - Olivier Steichen
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
- Assistance Publique - Hôpitaux de Paris (APHP), hôpital Tenon, Service de Médecine Interne, Paris, France
| | - Titouan Launay
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
| | - Cécile Conte
- INSERM, Université de Toulouse, Service de Pharmacologie médicale et clinique, CIC 1436, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - Béatrice Saint-Salvi
- Agence National de Sécurité du Médicaments et des produits de santé, Saint-Denis, 93200, France
| | - Clément Turbelin
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
| | - Marianne Sarazin
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
| | - Thierry Blanchon
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
| | - Thomas Hanslik
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
- Université de Versailles Saint-Quentin-en-Yvelines, UVSQ, UFR de Médecine, Versailles, France
- Assistance Publique - Hôpitaux de Paris (APHP), hôpital Ambroise Paré, Service de Médecine Interne, Boulogne Billancourt, France
| | - Maryse Lapeyre-Mestre
- INSERM, Université de Toulouse, Service de Pharmacologie médicale et clinique, CIC 1436, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - Louise Rossignol
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
- Département de Médecine Générale, Université Paris Cité, Paris, France
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Shang Z, Wanyan P, Zhang B, Wang M, Wang X. Incidence and risk factors of deep vein thrombosis in patients with spinal cord injury: a systematic review with meta-analysis. Front Cardiovasc Med 2023; 10:1153432. [PMID: 37252120 PMCID: PMC10213678 DOI: 10.3389/fcvm.2023.1153432] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/25/2023] [Indexed: 05/31/2023] Open
Abstract
Background Spinal cord injury (SCI) is a highly disabling disease with huge public health burden. The complications associated with it, especially deep vein thrombosis (DVT), further aggravate the disability. Objective To explore the incidence and risk factors of DVT after SCI, in order to provide guidance for disease prevention in the future. Methods A search was performed on PubMed, Web of Science, Embase, and Cochrane database up to November 9, 2022. Literature screening, information extraction and quality evaluation were performed by two researchers. The data was later combined by metaprop and metan commands in STATA 16.0. Results A total of 101 articles were included, including 223,221 patients. Meta-analysis showed that the overall incidence of DVT was 9.3% (95% CI: 8.2%-10.6%), and the incidence of DVT in patients with acute and chronic SCI was 10.9% (95% CI: 8.7%-13.2%) and 5.3% (95% CI: 2.2%-9.7%), respectively. The incidence of DVT decreased gradually with the accumulation of publication years and sample size. However, the annual incidence of DVT has increased since 2017. There are 24 kinds of risk factors that may contribute to the formation of DVT, involving multiple aspects of the baseline characteristics of the patient, biochemical indicators, severity of SCI, and comorbidities. Conclusions The incidence of DVT after SCI is high and has been gradually increasing in recent years. Moreover, there are numerous risk factors associated with DVT. Comprehensive preventive measures need to be taken as early as possible in the future. Systematic Review Registration www.crd.york.ac.uk/prospero, identifier CRD42022377466.
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Affiliation(s)
- Zhizhong Shang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Pingping Wanyan
- Department of Pathology and Pathophysiology, Gansu University of Chinese Medicine, Lanzhou, China
- Department of Nephrology, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Baolin Zhang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Mingchuan Wang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Xin Wang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
- Chengren Institute of Traditional Chinese Medicine, Lanzhou, China
- Department of Spine, Changzheng Hospital, Naval Medical University, Shanghai, China
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Cho MS, Choi HO, Hwang KW, Kim J, Nam GB, Choi KJ. Clinical benefits and risks of anticoagulation therapy according to the degree of chronic kidney disease in patients with atrial fibrillation. BMC Cardiovasc Disord 2023; 23:209. [PMID: 37098477 PMCID: PMC10131393 DOI: 10.1186/s12872-023-03236-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 04/11/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND The clinical benefits and risks of anticoagulation therapy in patients with chronic kidney disease (CKD) are still inconclusive. We describe the outcomes of patients with atrial fibrillation (AF) after anticoagulation therapy according to differences in creatinine clearance (CrCl). We also aimed to determine the patients who could benefit from anticoagulation therapy. METHODS This is a retrospective observational review of patients with AF who were managed at Asan Medical Center (Seoul, Korea) between January 1, 2006, and December 31, 2018. Patients were categorized into groups according to their baseline CrCl by Cockcroft-Gault equation and their outcomes were evaluated (CKD 1, ≥ 90 mL/min; CKD2, 60-89 mL/min; CKD3, 30-59 mL/min; CKD4, 15-29 mL/min; CKD 5, < 15 mL/min). The primary outcome was NACE (net adverse clinical events), defined as a composite of all-cause mortality, thromboembolic events, and major bleeding. RESULTS We identified 12,714 consecutive patients with AF (mean 64.6 ± 11.9 years, 65.3% male, mean CHA2DS2-VASc score 2.4 ± 1.6 points) between 2006 and 2017. In patients receiving anticoagulation therapy (n = 4447, 35.0%), warfarin (N = 3768, 84.7%) was used more frequently than NOACs (N = 673, 15.3%). There was a higher 3-year rate of NACE with renal function deterioration (14.8%, 18.6%, 30.3%, 44.0%, and 48.8% for CKD stages 1-5, respectively).The clinical benefit of anticoagulation therapy was most prominent in patients with CKD 1 (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.37-0.67), 2 (HR 0.64 CI 0.54-0.76), and 3 (HR 0.64 CI 0.54-0.76), but not in CKD 4 (HR 0.86, CI 0.57-1.28) and 5 (HR 0.81, CI 0.47-1.40). Among patients with CKD, the benefit of anticoagulation therapy was only evident in those with a high risk of embolism (CHA2DS2-VASc score ≥ 4, HR 0.25, CI 0.08-0.80). CONCLUSION Advanced CKD is associated with a higher risk of NACE. The clinical benefit of anticoagulation therapy was reduced with the increasing CKD stage.
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Affiliation(s)
- Min Soo Cho
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyung Oh Choi
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, 170, Jomaru-ro, Bucheon-si, Gyeonggi-do, 14584, Republic of Korea.
| | - Ki Won Hwang
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan, Republic of Korea
| | - Jun Kim
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gi-Byoung Nam
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kee-Joon Choi
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Kovačević V, Marinković MM, Kocijančić A, Isailović N, Simić J, Mihajlović M, Vučićević V, Potpara TS, Mujović NM. Long-Term Renal Function after Catheter Ablation of Atrial Fibrillation. J Cardiovasc Dev Dis 2023; 10:jcdd10040151. [PMID: 37103030 PMCID: PMC10142031 DOI: 10.3390/jcdd10040151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Background: Atrial fibrillation (AF) is associated with the development and progression of chronic kidney disease (CKD). This study evaluated the impact of long-term rhythm outcome after catheter ablation (CA) of AF on renal function. Methods and results: The study group included 169 consecutive patients (the mean age was 59.6 ± 10.1 years, 61.5% were males) who underwent their first CA of AF. Renal function was assessed by eGFR (using the CKD-EPI and MDRD formulas), and by creatinine clearance (using the Cockcroft–Gault formula) in each patient before and 5 years after index CA procedure. During the 5-year follow-up after CA, the late recurrence of atrial arrhythmia (LRAA) was documented in 62 patients (36.7%). The mean eGFR, regardless of which formula was used, significantly decreased at 5 years following CA in patients with LRAA (all p < 0.05). In the arrhythmia-free patients, the mean eGFR at 5 years post-CA remained stable (for the CKD-EPI formula: 78.7 ± 17.3 vs. 79.4 ± 17.4, p = 0.555) or even significantly improved (for the MDRD formula: 74.1 ± 17.0 vs. 77.4 ± 19.6, p = 0.029) compared with the baseline. In the multivariable analysis, the independent risk factors for rapid CKD progression (decline in eGFR > 5 mL/min/1.73 m2 per year) were the post-ablation LRAA occurrence (hazard ratio 3.36 [95% CI: 1.25–9.06], p = 0.016), female sex (3.05 [1.13–8.20], p = 0.027), vitamin K antagonists (3.32 [1.28–8.58], p = 0.013), or mineralocorticoid receptor antagonists’ use (3.28 [1.13–9.54], p = 0.029) after CA. Conclusions: LRAA after CA is associated with a significant decrease in eGFR, and it is an independent risk factor for rapid CKD progression. Conversely, eGFR in arrhythmia-free patients after CA remained stable or even improved significantly.
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19
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Greco A, Laudani C, Spagnolo M, Agnello F, Faro DC, Finocchiaro S, Legnazzi M, Mauro MS, Mazzone PM, Occhipinti G, Rochira C, Scalia L, Capodanno D. Pharmacology and Clinical Development of Factor XI Inhibitors. Circulation 2023; 147:897-913. [PMID: 36913497 DOI: 10.1161/circulationaha.122.062353] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Therapeutic anticoagulation is indicated for a variety of circumstances and conditions in several fields of medicine to prevent or treat venous and arterial thromboembolism. According to the different mechanisms of action, the available parenteral and oral anticoagulant drugs share the common principle of hampering or blocking key steps of the coagulation cascade, which unavoidably comes at the price of an increased propensity to bleed. Hemorrhagic complications affect patient prognosis both directly and indirectly (ie, by preventing the adoption of an effective antithrombotic strategy). Inhibition of factor XI (FXI) has emerged as a strategy with the potential to uncouple the pharmacological effect and the adverse events of anticoagulant therapy. This observation is based on the differential contribution of FXI to thrombus amplification, in which it plays a major role, and hemostasis, in which it plays an ancillary role in final clot consolidation. Several agents were developed to inhibit FXI at different stages (ie, suppressing biosynthesis, preventing zymogen activation, or impeding the biological action of the active form), including antisense oligonucleotides, monoclonal antibodies, small synthetic molecules, natural peptides, and aptamers. Phase 2 studies of different classes of FXI inhibitors in orthopedic surgery suggested that dose-dependent reductions in thrombotic complications are not paralleled by dose-dependent increases in bleeding compared with low-molecular-weight heparin. Likewise, the FXI inhibitor asundexian was associated with lower rates of bleeding compared with the activated factor X inhibitor apixaban in patients with atrial fibrillation, although no evidence of a therapeutic effect on stroke prevention is available so far. FXI inhibition could also be appealing for patients with other conditions, including end-stage renal disease, noncardioembolic stroke, or acute myocardial infarction, for which other phase 2 studies have been conducted. The balance between thromboprophylaxis and bleeding achieved by FXI inhibitors needs confirmation in large-scale phase 3 clinical trials powered for clinical end points. Several of such trials are ongoing or planned to define the role of FXI inhibitors in clinical practice and to clarify which FXI inhibitor may be most suited for each clinical indication. This article reviews the rationale, pharmacology, results of medium or small phase 2 studies, and future perspectives of drugs inhibiting FXI.
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Affiliation(s)
- Antonio Greco
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Claudio Laudani
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Marco Spagnolo
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Federica Agnello
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | | | - Simone Finocchiaro
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Marco Legnazzi
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Maria Sara Mauro
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | | | | | - Carla Rochira
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Lorenzo Scalia
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Davide Capodanno
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
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20
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Parker K, Choudhuri S, Lewis P, Thachil J, Mitra S. UK prescribing practice of anticoagulants in patients with chronic kidney disease: a nephrology and haematology-based survey. BMC Nephrol 2023; 24:9. [PMID: 36635661 PMCID: PMC9837988 DOI: 10.1186/s12882-022-03041-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/15/2022] [Indexed: 01/14/2023] Open
Abstract
A survey to gain insight into anticoagulant prescribing practice in the setting of chronic kidney disease (CKD) across the UK was disseminated via renal and haematology networks. Areas of anticoagulant use included patients with venous thromboembolism (VTE), requiring thromboprophylaxis for VTE, Atrial Fibrillation (AF) and nephrotic syndrome.An online-survey was disseminated via British Haematology Society, UK Kidney Association, and Renal Pharmacy Group over a five month period. All responses were voluntary and anonymous.Among 117 responses there were 49 nephrology doctors, 47 renal pharmacists and 20 haematology clinicians. A specialist multidisciplinary team to discuss the specific anticoagulant management of these patients was only available to 3% (4/117) respondents. Renal function estimate used for anticoagulant dosing was mainly Cockcroft-Gault for pharmacists and haematology but lab-based estimates were used by nephrology doctors. Therapeutic dose of Low Molecular Weight Heparin was mostly likely to be reduced by one-third when used for VTE treatment, with the majority of units undertaking anti-Xa monitoring in CKD stage 5 and dialysis. Direct-acting Oral Anticoagulants are being used in patients with nephrotic syndrome, those with CKD stage 5 and on dialysis for VTE and AF in the absence of license in these indications.This survey highlighted the significant differences between anticoagulant prescribing in CKD between two professional specialties and marked variation between centres in anticoagulant management strategies employed for these patients. With gaps still existing in the evidence base and answers to these not expected within the next few years, development of a best-practice guideline would be warranted to support clinicians in this field.
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Affiliation(s)
- Kathrine Parker
- grid.498924.a0000 0004 0430 9101Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, M13 9WL Manchester, UK ,grid.5379.80000000121662407Division of pharmacy and optometry, School of health sciences, Manchester Academic Health Science Centre, The University of Manchester, University of Manchester, M13 9PT Manchester, UK
| | - Satarupa Choudhuri
- grid.416187.d0000 0004 0400 8130Department of Haematology, Northern Care Alliance NHS Foundation Trust, Royal Oldham hospital, Rochdale Rd, OL1 2JH Oldham, UK
| | - Penny Lewis
- grid.5379.80000000121662407Division of pharmacy and optometry, School of health sciences, Manchester Academic Health Science Centre, The University of Manchester, University of Manchester, M13 9PT Manchester, UK
| | - Jecko Thachil
- grid.498924.a0000 0004 0430 9101Department of Haematology, Manchester University NHS Foundation Trust, Oxford Road, M13 9WL Manchester, UK
| | - Sandip Mitra
- grid.498924.a0000 0004 0430 9101Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, M13 9WL Manchester, UK ,grid.5379.80000000121662407Division of cardiovascular sciences, School of medical sciences, The University of Manchester, M13 9NT Manchester, UK
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21
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Altered Cerebral Blood Flow in the Progression of Chronic Kidney Disease. J Pers Med 2023; 13:jpm13010142. [PMID: 36675803 PMCID: PMC9863421 DOI: 10.3390/jpm13010142] [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: 11/27/2022] [Revised: 12/25/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023] Open
Abstract
Background: In chronic kidney disease (CKD), cognitive impairment is a definite complication. However, the mechanisms of how CKD leads to cognitive impairment are not clearly known. Methods: Cerebral blood flow (CBF) information was collected from 37 patients with CKD (18 in stage 3; 19 in stage 4) and 31 healthy controls (HCs). For CKD patients, we also obtained laboratory results as well as neuropsychological tests. We conducted brain perfusion imaging studies using arterial spin labeling and calculated the relationship between regional CBF changes and various clinical indicators and neuropsychological tests. We also generated receiver operator characteristic (ROC) curves to explore whether CBF value changes in certain brain regions can be used to identify CKD. Results: Compared with HCs, CBF decreased in the right insula and increased in the left hippocampus in the CKD4 group; through partial correlation analysis, we found that CBF in the right insula was negatively correlated with the number connection test A (NCT-A) (r = −0.544, p = 0.024); CBF in the left hippocampus was positively correlated with blood urea nitrogen (r = 0.649, p = 0.005) and negatively correlated with serum calcium level (r = −0.646, p = 0.005). By comparing the ROC curve area, it demonstrated that altered CBF values in the right insula (AUC = 0.861, p < 0.01) and left hippocampus (AUC = 0.862, p < 0.01) have a good ability to identify CKD. Conclusions: Our study found that CBF alterations in the left hippocampus and the right insula brain of adult patients with stage 4 CKD were correlated with disease severity or laboratory indicators. These findings provide further insight into the relationship between altered cerebral perfusion and cognitive impairment in patients with non-end-stage CKD as well as, additional information the underlying neuropathophysiological mechanisms.
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22
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Benz AP, Eikelboom JW. Apixaban Compared With Warfarin in Patients With Atrial Fibrillation and End-Stage Renal Disease: Lessons Learned. Circulation 2022; 146:1746-1748. [PMID: 36469596 DOI: 10.1161/circulationaha.122.061647] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Ontario, Canada (A.P.B., J.W.E.).,Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Germany (A.P.B.)
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Ontario, Canada (A.P.B., J.W.E.)
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23
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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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24
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Lui B, Wee B, Lai J, Khattak Z, Kwok A, Donarelli C, Ho P, Lim HY. A ten-year review of the impact of the transition from warfarin to direct oral anticoagulant - Has venous thromboembolism treatment become safer? Thromb Res 2022; 219:112-120. [PMID: 36162254 DOI: 10.1016/j.thromres.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 08/20/2022] [Accepted: 09/09/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND The introduction of direct oral anticoagulants (DOAC) has resulted in a paradigm shift in the management of venous thromboembolism (VTE). We evaluate the impact of the transition to DOAC, over the last decade, on overall VTE clinical outcomes including in first unprovoked major VTEs. METHOD A retrospective analysis of all VTE admissions in non-cancer patients from January 2011 to December 2020 at Northern Health, Victoria, Australia. "Warfarin era" included events that occurred between January 2011 and December 2014 and "DOAC era" from January 2016. RESULTS There were 2687 cases involving 2508 patients (45.9 % males; median age 63 years). 98 % were symptomatic and 1261 events (47 %) were unprovoked. 1003 events occurred during the warfarin era (79 % warfarin, 6 % DOAC) and 1479 during the DOAC era (18 % warfarin, 70 % DOAC). While recurrent thrombosis during the acute phase of treatment was comparable, there were fewer recurrences during the long-term preventative phase of treatment in the DOAC era compared to warfarin era (HR 0.602, 95 % CI: 0.393-0.924, p0.020). Clinically significant bleeding events were lower in the DOAC era (HR 0.623, 95 % CI: 0.395-0.985, p = 0.043). A subanalysis of first unprovoked major VTE events (n = 602) demonstrated a significant reduction in recurrent VTE during the long-term preventative phase of treatment in the DOAC era (HR 0.296, 95 % CI: 0.097-0.901, p = 0.032) with no difference in clinically significantly bleeding rates (HR 0.529, 95 % CI 0.219-1.280, p = 0.158) between the eras. CONCLUSION Treatment outcomes for VTE appear to have improved over time with reduced rate of thrombotic and clinically significant bleeding complications in the DOAC era.
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Affiliation(s)
- Brandon Lui
- Department of Haematology, Northern Health, Epping, VIC, Australia.
| | - Benjamin Wee
- Department of Haematology, Northern Health, Epping, VIC, Australia
| | - Jeffrey Lai
- Department of Haematology, Northern Health, Epping, VIC, Australia
| | - Zille Khattak
- Department of Haematology, Northern Health, Epping, VIC, Australia
| | - Anna Kwok
- Department of Haematology, Northern Health, Epping, VIC, Australia
| | | | - Prahlad Ho
- Department of Haematology, Northern Health, Epping, VIC, Australia; Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Hui Yin Lim
- Department of Haematology, Northern Health, Epping, VIC, Australia; Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
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Mikami T, Hirabayashi K, Okawa K, Betsuyaku T, Watanabe S, Imamura Y, Tanizawa K, Hayashi T, Akao M, Yamashita T, Okumura K. Laboratory Test Predictors for Major Bleeding in Elderly (≥80 Years) Patients With Nonvalvular Atrial Fibrillation Treated With Edoxaban 15 mg: Sub-Analysis of the ELDERCARE-AF Trial. J Am Heart Assoc 2022; 11:e024970. [PMID: 36056729 PMCID: PMC9496443 DOI: 10.1161/jaha.122.024970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background We investigated the predictors related to major bleeding events during treatment with edoxaban 15 mg in patients aged ≥80 years with nonvalvular atrial fibrillation and high bleeding risk, for whom standard oral anticoagulants are inappropriate, focusing on standard laboratory tests related to bleeding. Methods and Results This was a prespecified subanalysis of the on‐treatment analysis set of the ELDERCARE‐AF (Edoxaban Low‐Dose for Elder Care Atrial Fibrillation Patients) trial. Major bleeding was the primary safety end point. The event rates were calculated according to prespecified characteristics at baseline. A total of 984 Japanese patients were randomly assigned to edoxaban 15 mg or placebo (n=492, each). During the study period, 20 and 11 major bleeding events occurred in the edoxaban and placebo groups, respectively. The adjusted analysis revealed that hemoglobin <12.3 g/dL (adjusted hazard ratio [aHR], 3.57 [95% CI, 1.10–11.55]) and prothrombin time ≥12.7 seconds; (aHR, 2.89 [95% CI, 1.05–8.02]) independently predicted major bleeding, while creatinine clearance <30 mL/min showed a tendency towards an increase in major bleeding (aHR, 2.68; 95% CI, 0.96–7.46). In patients treated with edoxaban lacking these 3 risk factors, no major bleeding occurred; major bleeding event rates increased with each risk factor. Patients with 3 risk factors were significantly more likely to have a major bleeding event at 11.05%/year (HR, 7.15 [95% CI, 1.92–26.71]). Conclusions In elderly patients with nonvalvular atrial fibrillation with high bleeding risk, baseline hemoglobin <12.3 g/dL, prothrombin time ≥12.7 seconds, and creatinine clearance <30 mL/min may predict major bleeding during treatment with edoxaban 15 mg. Registration URL: ELDERCARE‐AF https://www.clinicaltrials.gov; Unique number: NCT02801669.
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Affiliation(s)
- Takeshi Mikami
- Department of Cardiology Munakata Suikokai General Hospital Fukutsu Japan
| | | | - Keisuke Okawa
- Department of Cardiology Kagawa Prefectural Central Hospital Takamatsu Japan
| | - Tetsuo Betsuyaku
- Department of Rehabilitation Tokyo Tenshi Hospital Hachioji Japan
| | - Saori Watanabe
- Clinical Development Department II, Development Function, Research and Development Division Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Yuki Imamura
- Clinical Development Department III, Development Function, Research and Development Division Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Kimihiko Tanizawa
- Clinical Development Department III, Development Function, Research and Development Division Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Takuya Hayashi
- Data Intelligence Group, Data Intelligence Department, Digital Transformation Management Division Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Masaharu Akao
- Department of Cardiology National Hospital Organization Kyoto Medical Center Kyoto Japan
| | | | - Ken Okumura
- Division of Cardiology Saiseikai Kumamoto Hospital Kumamoto Japan
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Sousa M, Cruz G, Vilela S, Cardoso C, Bravo P, Santos JP, Santos C, Silva J. Hemorrhagic Versus Ischemic Risk in Patients with Atrial Fibrillation on Hemodialysis. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2022. [DOI: 10.36660/ijcs.20210252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Kozieł-Siołkowska M, Siołkowski S, Mihajlovic M, Lip GY, Potpara TS. Predictors of Adherence to Stroke Prevention in the BALKAN-AF Study: A Machine-Learning Approach. TH OPEN 2022; 6:e283-e290. [DOI: 10.1055/s-0042-1755617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/27/2022] [Indexed: 10/14/2022] Open
Abstract
Abstract
Background Compared with usual care, guideline-adherent stroke prevention strategy, based on the ABC (Atrial fibrillation Better Care) pathway, is associated with better outcomes. Given that stroke prevention is central to atrial fibrillation (AF) management, improved efforts to determining predictors of adherence with ‘A’ (avoid stroke) component of the ABC pathway are needed.
Purpose We tested the hypothesis that more sophisticated methodology using machine learning (ML) algorithms could do this.
Methods In this post-hoc analysis of the BALKAN-AF dataset, ML algorithms and logistic regression were tested. The feature selection process identified a subset of variables that were most relevant for creating the model. Adherence with the ‘A’ criterion of the ABC pathway was defined as the use of oral anticoagulants (OAC) in patients with AF with a CHA2DS2-VASc score of 0 (male) or 1 (female).
Results Among 2,712 enrolled patients, complete data on ‘A’-adherent management were available in 2,671 individuals (mean age 66.0 ± 12.8; 44.5% female). Based on ML algorithms, independent predictors of ‘A-criterion adherent management’ were paroxysmal AF, center in capital city, and first-diagnosed AF. Hypertrophic cardiomyopathy, chronic kidney disease with chronic dialysis, and sleep apnea were independently associated with a lower likelihood of ‘A’-criterion adherent management.ML evaluated predictors of adherence with the ‘A’ criterion of the ABC pathway derived an area under the receiver-operator curve of 0.710 (95%CI 0.67–0.75) for random forest with fine tuning.
Conclusions Machine learning identified paroxysmal AF, treatment center in the capital city, and first-diagnosed AF as predictors of adherence to the A pathway; and hypertrophic cardiomyopathy, chronic kidney disease with chronic dialysis, and sleep apnea as predictors of non adherence.
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Affiliation(s)
- Monika Kozieł-Siołkowska
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- 1st Department of Cardiology and Angiology, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Sebastian Siołkowski
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | | | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- 1st Department of Cardiology and Angiology, Silesian Centre for Heart Diseases, Zabrze, Poland
- School of Medicine, Belgrade University, Belgrade, Serbia
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tatjana S. Potpara
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
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Wang J, Zhang T, Yang YM, Zhu J, Zhang H, Shao XH. Relationship between creatinine clearance and clinical outcomes in Chinese emergency patients with atrial fibrillation. Ann Noninvasive Electrocardiol 2022; 27:e12942. [PMID: 35239203 PMCID: PMC9107078 DOI: 10.1111/anec.12942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 12/02/2022] Open
Abstract
Background Few real‐world data on the relation between creatinine clearance (CrCl) and adverse clinical outcomes in Chinese emergency department (ED) patients with nonvalvular atrial fibrillation (AF). Methods In this prospective, observational, multicenter AF study, enrolled AF patients presenting to an ED at 20 hospitals in China from November 2008 to October 2011, with a follow‐up of 12 month. A total of 863 AF patients with CrCl data were analyzed, and patients were categorized as CrCl ≥ 80, 50 ≤ CrCl < 80, 30 ≤ CrCl < 50, and CrCl < 30(ml/min). Outcomes of analyses were all‐cause death, cardiovascular death, thromboembolism (TE), and major bleeding. Results Among the whole patients, 126(14.6%) patients died during 12‐month follow‐up, 53(40.2%) among CrCl < 30 ml/min group, and 48(16.2%), 22(6.5%), and 3(3.2%) among 30 ≤ CrCl50, 50 ≤ Crl < 80, and CrCl ≥ 80 ml/min groups, respectively (p < 0.001). Cardiovascular death and TE rates also increased with decreasing CrCl. On multivariate analysis, patients with CrCl < 30 ml/min were associated with higher risks of all‐cause death (HR 5.567; 95%CI1.618–19.876; p = .007) and higher cardiovascular death (HR11.939; 95%CI1.439–99.031; p = .022) as compared with CrCl≥80 ml/min category. Nevertheless, for TE and major bleeding risk, CrCl groups showed no significant difference after adjustment for variables in CHA2DS2‐VASc score and status of warfarin prescription in our cohort. Conclusions In Chinese ED nonvalvular AF patients, incidence rates of death increased with reducing CrCl across the whole range of renal function. CrCl < 30 ml/min was associated with all‐cause death, cardiovascular death, but not for TE and major bleeding.
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Affiliation(s)
- Juan Wang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Zhang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan-Min Yang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhu
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Han Zhang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xing-Hui Shao
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Su X, Yan B, Wang L, Cheng H, Chen Y. Comparative efficacy and safety of oral anticoagulants for the treatment of venous thromboembolism in the patients with different renal functions: a systematic review, pairwise and network meta-analysis. BMJ Open 2022; 12:e048619. [PMID: 35190410 PMCID: PMC8862458 DOI: 10.1136/bmjopen-2021-048619] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To compare the efficacy and safety of direct oral anticoagulants (DOACs) in patients with venous thromboembolism (VTE) and different renal functions. DESIGN Systematic review containing pairwise and Bayesian network meta-analysis of randomised controlled trials (RCTs). DATA SOURCES MEDLINE, EMBASE and Cochrane Library. ELIGIBILITY CRITERIA RCTs reporting the efficacy and safety outcomes of DOACs in different creatinine clearance (CrCl) subgroups. DATA EXTRACTION AND SYNTHESIS Data extraction and quality assessment were undertaken by two independent reviewers. Data were pooled using the DerSimonian-Laird method in pairwise meta-analysis. Network meta-analysis within a Bayesian framework was conducted. RESULTS Data from 10 RCTs were included. In the treatment of acute VTE, DOACs did not significantly reduce recurrent VTE or VTE-related death (OR, 0.96; 95% CI, 0.82 to 1.11) but significantly reduced bleeding events (0.76, 0.68 to 0.90) compared with warfarin. In the extended treatment of VTE, DOACs produced significant benefits in recurrent VTE or VTE-related death (0.23, 0.16 to 0.29), but significantly increased bleeding events (1.86, 1.04 to 3.33) compared with placebo/aspirin. There were no significant differences in efficacy and safety of DOACs among the three CrCl stratified subgroups in acute and extended treatment of VTE (p for subgroup heterogeneity >0.1). Bayesian network meta-analysis suggested that apixaban 2.5 mg and 5 mg two times per day were associated with a lower risk of bleeding than dabigatran, rivaroxaban, warfarin and aspirin in the subgroup with CrCl >80 mL/min. CONCLUSIONS For the treatment of acute VTE, DOACs are similar to warfarin in reducing recurrent VTE and VTE-related death but are significantly superior to warfarin in reducing the risk of bleeding. For the efficacy and safety of DOACs across different CrCl stratifications (30-50, 50-80 and more than 80 mL/min), no significant difference was found. In light of minimal evidence, apixaban might be associated with a lower risk of bleeding in patients with VTE and CrCl >80 mL/min. PROSPERO REGISTRATION NUMBER CRD42018090896.
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Affiliation(s)
- Xiaole Su
- Department of Nephrology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang District, Beijing, China
- Department of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, China
| | - Bingjuan Yan
- Department of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, China
| | - Lihua Wang
- Department of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, China
| | - Hong Cheng
- Department of Nephrology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang District, Beijing, China
| | - Yipu Chen
- Department of Nephrology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang District, Beijing, China
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Huang WC, Wang MT, Lai TS, Lee KH, Shao SC, Chen CH, Su CH, Chen YT, Sung JM, Chen YC. Nephrotoxins and acute kidney injury - The consensus of the Taiwan acute kidney injury Task Force. J Formos Med Assoc 2022; 121:886-895. [PMID: 34998658 DOI: 10.1016/j.jfma.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 12/01/2021] [Accepted: 12/14/2021] [Indexed: 12/15/2022] Open
Abstract
The Taiwan Acute Kidney Injury (AKI) Task Force conducted a review of data and developed a consensus regarding nephrotoxins and AKI. This consensus covers: (1) contrast-associated AKI; (2) drug-induced nephrotoxicity; (3) prevention of drug-associated AKI; (4) follow up after AKI; (5) re-initiation of medication after AKI. Strategies for the avoidance of contrast media related AKI, including peri-procedural hydration, sodium bicarbonate solutions, oral N-acetylcysteine, and iso-osmolar/low-osmolar non-ionic iodinated contrast media have been recommended, given the respective evidence levels. Regarding anticoagulants, both warfarin and new oral anticoagulants have potential nephrotoxicity, and dosage should be reduced if renal pathology exam proves renal injury. Recommended strategies to prevent drug related AKI have included assessment of 5R/(6R) reactions - risk, recognition, response, renal support, rehabilitation and (research), use of AKI alert system and computerized decision support. In terms of antibiotics-associated AKI, avoiding concomitant administration of vancomycin and piperacillin-tazobactam, monitoring vancomycin trough level, switching from vancomycin to teicoplanin in high-risk patients, and replacing conventional amphotericin B with lipid-based amphotericin B have been shown to reduce drug related AKI. With respect to non-steroidal anti-inflammatory drug associated AKI, it is recommended to use these drugs cautiously in the elderly and in patients receiving renin-angiotensin-aldosterone system inhibitors/diuretics triple combinations.
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Affiliation(s)
- Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan; Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mei-Tzu Wang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Tai-Shuan Lai
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuo-Hua Lee
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Chieh Shao
- Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chien-Hao Chen
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Hao Su
- Department of Pharmacy, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yih-Ting Chen
- Division of Nephrology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Junne-Ming Sung
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yung-Chang Chen
- Division of Critical Care Nephrology, Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taipei, Taiwan; Chang Gung University College of Medicine, Taiwan.
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Survival Benefit of Anticoagulation Therapy in End Stage Kidney Disease Patients with Atrial Fibrillation: A Single Center Retrospective Study. Medicina (B Aires) 2021; 58:medicina58010058. [PMID: 35056366 PMCID: PMC8780499 DOI: 10.3390/medicina58010058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Although the need for anticoagulation to prevent thromboembolism is increasing and non-vitamin K antagonist oral anticoagulants (NOACs) have been tried, there is still controversy about the efficacy of anticoagulation in patients with dialysis. Materials and Methods: We retrospectively analyzed the risk and benefit of anticoagulation in dialysis patients with atrial fibrillation (AF). We retrospectively analyzed all data of 89 patients who received dialysis therapy and were diagnosed with AF. Among them, 27 received anticoagulation (11 warfarin and 16 apixaban 2.5 mg twice a day), while 62 received no anticoagulation. Results: In multivariate Cox regression analysis, compared to no anticoagulation treatment, anticoagulation treatment was associated with a low incidence of all-cause mortality (hazard ratios (HR) 0.36; 95% confidence interval (CI) 0.15–0.88). Compared to no anticoagulation treatment, more anticoagulation treatment patients experienced severe bleeding (HR 4.67; 95% CI 1.26–17.25) and any bleeding (HR 2.79; 95% CI 1.01–7.74). Compared to no anticoagulation, warfarin treatment patients were associated with a low incidence of all-cause mortality (HR 0.26; 95% CI 0.09–0.81) and a high incidence of severe bleeding (HR 4.85; 95% CI 1.12–21.10). All-cause mortality and bleeding were not significantly different between no anticoagulation and apixaban treatment patients. Conclusions: In dialysis patients with AF, anticoagulation therapy is associated with an increased incidence of severe bleeding, but anticoagulation therapy is associated with a low incidence of all-cause mortality. Individualized anticoagulation therapy with careful bleeding monitoring is needed in dialysis patients with AF.
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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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Wee HN, Liu JJ, Ching J, Kovalik JP, Lim SC. The Kynurenine Pathway in Acute Kidney Injury and Chronic Kidney Disease. Am J Nephrol 2021; 52:771-787. [PMID: 34753140 PMCID: PMC8743908 DOI: 10.1159/000519811] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The kynurenine pathway (KP) is the major catabolic pathway for tryptophan degradation. The KP plays an important role as the sole de novo nicotinamide adenine dinucleotide (NAD+) biosynthetic pathway in normal human physiology and functions as a counter-regulatory mechanism to mitigate immune responses during inflammation. Although the KP has been implicated in a variety of disorders including Huntington's disease, seizures, cardiovascular disease, and osteoporosis, its role in renal diseases is seldom discussed. SUMMARY This review summarizes the roles of the KP and its metabolites in acute kidney injury (AKI) and chronic kidney disease (CKD) based on current literature evidence. Metabolomics studies demonstrated that the KP metabolites were significantly altered in patients and animal models with AKI or CKD. The diagnostic and prognostic values of the KP metabolites in AKI and CKD were highlighted in cross-sectional and longitudinal human observational studies. The biological impact of the KP on the pathophysiology of AKI and CKD has been studied in experimental models of different etiologies. In particular, the activation of the KP was found to confer protection in animal models of glomerulonephritis, and its immunomodulatory mechanism may involve the regulation of T cell subsets such as Th17 and regulatory T cells. Manipulation of the KP to increase NAD+ production or diversion toward specific KP metabolites was also found to be beneficial in animal models of AKI. Key Messages: KP metabolites are reported to be dysregulated in human observational and animal experimental studies of AKI and CKD. In AKI, the magnitude and direction of changes in the KP depend on the etiology of the damage. In CKD, KP metabolites are altered with the onset and progression of CKD all the way to advanced stages of the disease, including uremia and its related vascular complications. The activation of the KP and diversion to specific sub-branches are currently being explored as therapeutic strategies in these diseases, especially with regards to the immunomodulatory effects of certain KP metabolites. Further elucidation of the KP may hold promise for the development of biomarkers and targeted therapies for these kidney diseases.
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Affiliation(s)
| | - Jian-Jun Liu
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Jianhong Ching
- Duke-NUS Medical School, Singapore, Singapore
- KK Research Centre, KK Women's and Children's Hospital, Singapore, Singapore
| | | | - Su Chi Lim
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Diabetes Centre, Admiralty Medical Centre, Singapore, Singapore
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Novikova TN. [Features of anticoagulant therapy of atrial fibrillation in combination with impaired renal function]. KARDIOLOGIIA 2021; 61:81-88. [PMID: 34763642 DOI: 10.18087/cardio.2021.10.n1767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/27/2021] [Indexed: 06/13/2023]
Abstract
This review focuses on issues of anticoagulant therapy in patients with atrial fibrillation (AF) associated with chronic kidney disease (CKD). Such patients are at high risk of stroke whereas the choice of an anticoagulant is difficult. A wealth of information about a negative effect of warfarin on the kidney function has accumulated. A need for an alternative therapy to warfarin for patients with stage 3-4 CKD has become imminent. In this regard, rivaroxaban seems to be an appropriate replacement for warfarin in such patients. In randomized, controlled studies that evaluated the efficacy of direct oral anticoagulants in comparison with warfarin, the efficacy and safety profile of a "kidney" dose in moderate disorders of kidney function has been studied only for rivaroxaban. Moreover, both randomized, controlled studies and studies performed in the conditions of clinical practice, have demonstrated a more favorable effect of rivaroxaban on kidney function compared to warfarin. Patients with AF associated with CKD require a comprehensive protection, which, according to results of clinical studies, may be provided by rivaroxaban.
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Affiliation(s)
- T N Novikova
- I.I. Mechnikov North-Western State Medical University, Saint Petersburg
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35
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Eikelboom J, Floege J, Thadhani R, Weitz JI, Winkelmayer WC. Anticoagulation in patients with kidney failure on dialysis: factor XI as a therapeutic target. Kidney Int 2021; 100:1199-1207. [PMID: 34600964 DOI: 10.1016/j.kint.2021.08.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 12/18/2022]
Abstract
Chronic kidney disease is present in almost 10% of the world population and is associated with excess mortality and morbidity. Reduced glomerular filtration rate and the presence and extent of proteinuria, key domains of chronic kidney disease, have both been shown to be strong and independent risk factors for cardiovascular disease. Patients with kidney failure requiring dialysis are at highest risk for cardiovascular events (e.g., stroke or myocardial infarction), and of developing chronic cardiovascular conditions, such as heart failure. Despite the high burden of cardiovascular disease, there is a paucity of evidence supporting therapies to reduce this risk. Although long-term anticoagulant treatment has the potential to prevent thromboembolism in persons with kidney failure on dialysis, this possibility remains understudied. The limited data available on anticoagulation in patients with kidney failure has focused on vitamin K antagonists or direct oral anticoagulants that inhibit thrombin or factor (F) Xa. The risk of bleeding is a major concern with these agents. However, FXI is emerging as a potential safer target for new anticoagulants because FXI plays a greater part in thrombosis than in hemostasis. In this article, we (i) explain the rationale for considering anticoagulation therapy in patients with kidney failure to reduce atherothrombotic events, (ii) highlight the limitations of current anticoagulants in this patient population, (iii) explain the potential benefits of FXI inhibitors, and (iv) summarize ongoing studies investigating FXI inhibition in patients with kidney failure on dialysis.
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Affiliation(s)
- John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jürgen Floege
- Department of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Ravi Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Wolfgang C Winkelmayer
- Department of Medicine, Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas, USA.
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Vrana E, Kartas A, Samaras A, Vasdeki D, Forozidou E, Liampas E, Karvounis H, Giannakoulas G, Tzikas A. Indications for percutaneous left atrial appendage occlusion in hospitalized patients with atrial fibrillation. J Cardiovasc Med (Hagerstown) 2021; 23:176-182. [PMID: 34580251 DOI: 10.2459/jcm.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Percutaneous left atrial appendage occlusion (LAAO) is an alternative nonpharmacological therapeutic option for stroke prevention in patients with NVAF. However, no data exist on potential LAAO candidates' prevalence among 'real-world' NVAF patients. This study aimed to investigate the indications for LAAO in hospitalized patients with comorbid nonvalvular atrial fibrillation (NVAF). METHODS This is a post-hoc analysis of the MISOAC-AF (Motivational Interviewing to Support OAC-AF, ClinicalTrials.gov: NCT02941978), randomized controlled trial, which enrolled NVAF patients hospitalized for any reason in a tertiary cardiology department. In this analysis, patients with a history of major bleeding or stroke under OAC therapy were considered to have a strong indication for LAAO. RESULTS A total of 980 patients with NVAF were studied (mean age 73.9 ± 10.9 years, 54.7% men). Prior major bleeding occurred in 134 (13.7%) patients (intracranial bleeding in 1%, upper and lower gastrointestinal bleeding in 6.4 and 8.9%, respectively). A total of 58 (5.9%) patients experienced an embolic stroke while being treated using OAC. Overall, either of these events was prevalent in 173 (17.7%) patients, denoting a strong indication for LAAO. CONCLUSION Almost one out of six patients hospitalized with comorbid NVAF may be considered eligible for percutaneous LAAO for stroke prevention.Trial Identification: NCT02941978, https://clinicaltrials.gov/ct2/show/NCT02941978.
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Affiliation(s)
- Eleni Vrana
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki Department of Cardiology, Interbalkan European Medical Center, Pylaia, Thessaloniki, Greece
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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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Parker K, Chu J, Morton M, Bhutani S, Picton M, Mitra S, Thachil J. Can direct oral anticoagulants be used in kidney transplant recipients? Clin Transplant 2021; 35:e14474. [PMID: 34498777 DOI: 10.1111/ctr.14474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 08/10/2021] [Accepted: 09/01/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Kidney transplant recipients(KTRs) are at an increased risk of venous thromboembolism (VTE) and atrial fibrillation(AF). Direct oral anticoagulants (DOACs) have shown important advantages over vitamin K antagonists; however, in KTRs, concerns regarding interactions and use in severe kidney disease may limit their use. This evaluation describes a large UK kidney transplant center's experience of DOACs in KTRs with CrCl > 15 mL/min. METHODS Electronic records were reviewed for all adult KTRs at Manchester University Foundation Trust Hospitals taking DOACs between January 2018 and October 2020 with VTE or AF. The primary outcome was trough and peak DOAC levels within the expected reference ranges and secondary outcomes included bleeding and thrombotic events. RESULTS In 31 KTRs taking DOACS, eight patients had a CrCl < 30 mL/min. Overall, 94% (62/66) of DOAC levels were within the recommended ranges. There were no thrombotic events and four bleeding events (two major and two clinically relevant non-major bleeds). The overall bleeding rate was 6.9 per 100 patient-years at risk. CONCLUSIONS There was no evidence of a significant interaction of apixaban or rivaroxaban with CNIs based on expected DOAC and CNI levels. Their use was found to be safe and effective with no VTE events and bleeding episodes similar to published trial data.
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Affiliation(s)
- Kathrine Parker
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK.,Division of Pharmacy and Optometry, School of Health Sciences, Academic Health Science Centre, University of Manchester, Manchester, The University of Manchester, Manchester, UK
| | - Janette Chu
- Department of Pharmacy, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Muir Morton
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Shiv Bhutani
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Michael Picton
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Sandip Mitra
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK.,The University of Manchester, Division of Cardiovascular Sciences, School of Medical Sciences, Manchester, UK
| | - Jecko Thachil
- Department of Haematology, Manchester University NHS Foundation Trust, Oxford Road, Manchester, UK
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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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Kotta PA, Elango M, Papalois V. Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review. J Clin Med 2021; 10:2525. [PMID: 34200235 PMCID: PMC8201125 DOI: 10.3390/jcm10112525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 12/23/2022] Open
Abstract
Patients with end-stage kidney disease (ESKD) have a high prevalence of cardiovascular disease; it is the leading cause of death in these patients and the optimisation of their cardiovascular health may improve their post-transplant outcomes. Patients awaiting renal transplant often spend significant amounts of time on the waiting list allowing for the assessment and optimisation of their cardiovascular system. Coronary artery disease (CAD) is commonly seen in these patients and we explore the possible functional and anatomical investigations that can help assess and manage CAD in renal transplant candidates. We also discuss other aspects of cardiovascular assessment and management including arrhythmias, impaired ventricular function, valvular disease, lifestyle and pulmonary arterial hypertension. We hope that this review can form a basis for centres hoping to implement an enhanced recovery after surgery (ERAS) protocol for renal transplantation.
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Affiliation(s)
| | - Madhivanan Elango
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
| | - Vassilios Papalois
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
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Ferrari F, da Silveira AD, Martins VM, Franzoni LT, Zimerman LI, Stein R. Direct-Acting Oral Anticoagulants in Atrial Fibrillation: What's New in the Literature. Cardiol Rev 2021; 29:120-130. [PMID: 32332235 DOI: 10.1097/crd.0000000000000312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation (AF) is considered the most common sustained cardiac arrhythmia, and it is associated with a significant risk of adverse events, especially ischemic stroke. Oral anticoagulation is the cornerstone for stroke prevention in AF; for many years, only vitamin K antagonists were used for this purpose, with an absolute risk reduction >60%. However, these agents have limitations, such as narrow therapeutic margins and drug-food and drug-drug interactions. More recently, 4 direct-acting oral anticoagulants (DOACs)-non-vitamin K antagonists-have become available for patients with AF: dabigatran, rivaroxaban, apixaban, and edoxaban. In addition to a comparable efficacy to warfarin in large randomized controlled trials, DOACs were found to promote a lower risk of intracranial bleeding. The strategic dosage and lack of need for periodic prothrombin-time testing make their use attractive, especially for primary or secondary prevention of stroke in older adults. Furthermore, among patients with AF presenting with acute coronary syndrome or undergoing percutaneous coronary intervention, apixaban is associated with a reduction in serious bleeding events when compared with warfarin. On the other hand, there is no evidence of benefit of DOACs in patients with mechanical prosthetic valves or moderate/severe mitral stenosis. Furthermore, the suitability of DOACs in patients with liver disease is still poorly understood, and their safety in patients requiring renal replacement therapy remains uncertain. This review provides an overview of the main trials of DOACs, their pharmacology and safety profile, clinical implications, and best indications in light of the current evidence.
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Affiliation(s)
- Filipe Ferrari
- From the Postgraduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Exercise Cardiology Research Group (CardioEx), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Anderson Donelli da Silveira
- From the Postgraduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Exercise Cardiology Research Group (CardioEx), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Vitor Magnus Martins
- From the Postgraduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Leandro Tolfo Franzoni
- From the Postgraduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Exercise Cardiology Research Group (CardioEx), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Ricardo Stein
- From the Postgraduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Exercise Cardiology Research Group (CardioEx), Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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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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Su X, Yan B, Wang L, Lv J, Cheng H, Chen Y. Oral Anticoagulant Agents in Patients With Atrial Fibrillation and CKD: A Systematic Review and Pairwise Network Meta-analysis. Am J Kidney Dis 2021; 78:678-689.e1. [PMID: 33872690 DOI: 10.1053/j.ajkd.2021.02.328] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 02/02/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the relative efficacy and safety of different oral anticoagulant agents (OACs) for patients with atrial fibrillation (AF) and chronic kidney disease (CKD). STUDY DESIGN Systematic review and pairwise and Bayesian network meta-analysis. SETTING & STUDY POPULATIONS Adult patients with AF and CKD stages 3-5D who received OACs. SELECTION CRITERIA FOR STUDIES Randomized controlled trials (RCTs) and observational studies that reported the efficacy and safety outcomes of subgroups with a glomerular filtration rate (GFR)<60mL/min. DATA EXTRACTION Two reviewers independently abstracted data, assessed study quality, and rated the strength of evidence (SOE). ANALYTICAL APPROACH Random-effects models using restricted maximum-likelihood methods were fit for the pairwise meta-analyses as well as a network meta-analysis within a Bayesian framework. RESULTS Pairwise meta-analysis including 8 RCTs and 46 observational studies showed that direct OACs (DOACs) were superior to warfarin in preventing thromboembolic events (hazard ratio [HR], 0.86 [95% CI, 0.78-0.95]), without heterogeneity (I2=10.5%), and in reducing the risk of bleeding events (HR, 0.81 [95% CI, 0.66-0.99]), with substantial heterogeneity (I2=69.8%), in patients with AF and a GFR of 15-60mL/min. Bayesian network meta-analysis including 8 RCTs showed that dose-adjusted apixaban and a 15-mg dose of edoxaban were superior to the other OAC regimens in reducing bleeding events. Dose-adjusted apixaban was more effective than edoxaban in preventing thromboembolic events for patients with AF and GFR in the range of 25-50 or 30-50mL/min. In dialysis recipients with AF, the use of OACs increased the risk of bleeding events by 28% (HR, 1.28 [95% CI, 1.03-1.60]) without significant beneficial effects versus not using anticoagulants. LIMITATIONS Low SOE and heterogeneity in most comparisons. CONCLUSIONS This study suggests that DOACs are superior to warfarin for the prevention of thromboembolic events and reduction in bleeding risk in patients with AF and mild to moderate kidney disease. However, the low SOE limits the conclusions that can be drawn about the preferred DOAC. Notably, the use of OACs may increase bleeding risk without significant benefits in dialysis recipients with AF. REGISTRATION Registered at PROSPERO with identification number CRD42018090896.
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Affiliation(s)
- Xiaole Su
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University; Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, China
| | - Bingjuan Yan
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, China
| | - Lihua Wang
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, China
| | - Jicheng Lv
- Division of Nephrology, Peking University First Hospital, Peking University Institute of Nephrology, Beijing
| | - Hong Cheng
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University
| | - Yipu Chen
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University.
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Gomez-Fernández P, Martín Santana A, Arjona Barrionuevo JDD. Oral anticoagulation in chronic kidney disease with atrial fibrillation. Nefrologia 2021; 41:137-153. [PMID: 36165375 DOI: 10.1016/j.nefroe.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 08/11/2020] [Indexed: 06/16/2023] Open
Abstract
Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist, amplifying the risk of cardiovascular events and mortality. In patients with CKD stage 3 and non-valvular AF, direct oral anticoagulants (DOACs) have shown, compared to vitamin K antagonists (VKA), equal or greater efficacy in the prevention of stroke and systemic embolism, and greater safety. There are no randomizedtrials of the efficacy and safety of DOACs and VKA in advanced CKD. On the other hand, observational studies suggest that DOACs, compared to warfarin, are associated with a lower risk of acute kidney damage and generation/progression of CKD. This paper reviews the epidemiological and pathophysiological aspects of the CKD and AF association, the evidence of the efficacy and safety of warfarin and ACODs in various stages of CKD with AF as well as the comparison between warfarin and ACODs in efficacy and anticoagulant safety, and in its renal effects.
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Affiliation(s)
- Pablo Gomez-Fernández
- Unidad de Factores de Riesgo Vascular, Servicio de Nefrología, Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain.
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45
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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: 5051] [Impact Index Per Article: 1683.7] [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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46
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Limdi NA, Beasley TM, Sun J, Stockbridge N, Pacanowski M, Florian J. Thromboembolic and Hemorrhagic Outcomes in the Direct Oral Anticoagulant Trials Across the Spectrum of Kidney Function. Clin Pharmacol Ther 2021; 109:1593-1605. [PMID: 33278832 DOI: 10.1002/cpt.2131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/19/2020] [Indexed: 12/12/2022]
Abstract
Chronic kidney disease is a common comorbidity among patients taking direct-acting oral anticoagulants (DOACs). Herein, we evaluate the influence of kidney function on stroke or systemic embolism (SEE), hemorrhage, and composite end points (stroke/SEE/hemorrhage/death and stroke/SEE/death) among patients on DOACs and warfarin. Baseline kidney function was categorized as glomerular filtration rate (GFR) ≥ 60 (reference), 45-59, and < 45mL/min/1.73 m2 for participants in the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) (n = 18,049), Apixaban for Reduction in Stroke and Other Thromboembolic Events (ARISTOTLE) (n = 18,187), and The Effective Anticoagulation with Factor Xa Next Generation in AF (ENGAGE AF) (n = 20,798) trials. Incidence of events was compared across GFR categories. Hazard ratios for events were estimated using Cox regression using intention-to-treat analysis adjusting for known predictors. A large proportion of participants had GFR < 60 (25-29% had 45 ≤ GFR < 60 and 9.5-12.6% with GFR < 45). Compared with patients with GFR ≥ 60, warfarin users across the trials with GFR ≥ 45-59 and GFR < 45 had a higher incidence of hemorrhage (P values < 0.0001) and warfarin users in the ARISTOTLE and ENGAGE trials had higher incidence of stroke/SEE (P values ≤ 0.05). Compared with patients with GFR ≥ 60, dabigatran users with GFR ≥ 45-59 and GFR < 45 had a higher incidence of stroke/SEE (P ≤ 0.02), hemorrhage (P < 0.001), and both composite end points (P < 0.0001). Compared with patients with GFR ≥ 60, apixaban and edoxaban users with GFR ≥ 45-59 and GFR < 45 had a higher incidence of hemorrhage (P values ≤ 0.05) and composite end points (P values ≤ 0.05). After adjustment, compared with patients with GFR ≥ 60, warfarin users with GFR < 60 in the ARISTOTLE and RE-LY trials had a higher risk of hemorrhage (P < 0.05), as did dabigatran (P < 0.001) and edoxaban (P ≤ 0.005) users, while apixaban users did not exhibit an increased risk (P = 0.08 GFR ≥ 45-59; P = 0.71 GFR < 45). Kidney function significantly influences the safety and efficacy of oral anticoagulants.
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Affiliation(s)
- Nita A Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Timothy Mark Beasley
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jielin Sun
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, Office of New Drugs I, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Michael Pacanowski
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jeffry Florian
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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47
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Ning X, Kuang Y, Yang G, Xie J, Miao D, Guo C, Huang Z. Influence of renal insufficiency on anticoagulant effects and safety of warfarin in Chinese patients: analysis from a randomized controlled trial. Naunyn Schmiedebergs Arch Pharmacol 2021; 394:1275-1283. [PMID: 33404689 PMCID: PMC8208902 DOI: 10.1007/s00210-020-02037-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/01/2020] [Indexed: 12/19/2022]
Abstract
This study aimed to analyze the influence of renal insufficiency on the anticoagulant effects and safety of warfarin in Chinese patients. Data on the creatinine levels of participants enrolled in a randomized controlled study were screened and divided into the non-renal insufficiency group, mild renal insufficiency group, and moderate renal insufficiency group, according to the creatinine clearance rate. The primary outcome measures were stable dose and average daily dose of warfarin. Secondary outcome measures were percentage of time in the therapeutic international normalized ratio (INR) (%TTR), and the first time to reach the therapeutic INR. Adverse events included bleeding events, thromboembolic events, and mortality. All participants with renal function test results and a baseline INR of less than 1.5 were included in the primary and secondary outcome analysis. The SPSS Statistics 21.0 software was used for statistical analysis. The randomized controlled trial was registered in Clinicaltrials.gov (NCT02211326). A total of 571 patients were included in this analysis. Multiple regression analysis showed that the renal function was correlated with stable dose, average daily dose, and the first time to reach therapeutic INR after adjusting for confounding factors. However, no correlation was noted between kidney function and %TTR. No significant differences were observed across the various safety parameters among the three groups. Renal function is an important consideration in patients using warfarin.
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Affiliation(s)
- Xiaoyi Ning
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China
| | - Yun Kuang
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China
| | - Guoping Yang
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China.,Research Center for Drug Clinical Evaluation of Central South University, Changsha, 410013, Hunan, China.,Department of Pharmacy, the Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Jinlian Xie
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China
| | - Da Miao
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China
| | - Chengxian Guo
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China. .,Research Center for Drug Clinical Evaluation of Central South University, Changsha, 410013, Hunan, China. .,Department of Pharmacy, the Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
| | - Zhijun Huang
- Center for Clinical Pharmacology, the Third Xiangya Hospital, Central South University, 138 TongZiPo Road, Changsha, 410013, Hunan, China. .,Department of Nephrology, the Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
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48
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Camm AJ, Atar D. Use of Non-vitamin K Antagonist Oral Anticoagulants for Stroke Prevention across the Stroke Spectrum: Progress and Prospects. Thromb Haemost 2021; 121:716-730. [PMID: 33412613 DOI: 10.1055/s-0040-1721665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Multiple randomized controlled trials and many real-world evidence studies have consistently shown that non-vitamin K antagonist oral anticoagulants (NOACs) are preferable to vitamin K antagonists for thromboembolic stroke prevention in the majority of patients with atrial fibrillation (AF). However, their role in the management of patients with AF and comorbidities, as well as in other patient populations with a high risk of stroke, such as patients with prior embolic stroke of undetermined source (ESUS) and those with atherosclerosis, is less clear. There is now increasing evidence suggesting that NOACs have a beneficial effect in the prevention of stroke in patients with AF and comorbidities, such as renal impairment and diabetes. In addition, while studies investigating the efficacy and safety of NOACs for the prevention of secondary stroke in patients with a history of ESUS demonstrated neutral results, subanalyses suggested potential benefits in certain subgroups of patients with ESUS. One NOAC, rivaroxaban, has also recently been found to be effective in reducing the risk of stroke in patients with chronic cardiovascular disease including coronary artery disease and peripheral artery disease, further broadening the patient groups that may benefit from NOACs. In this article, we will review recent evidence for the use of NOACs across the stroke spectrum in detail, and discuss the progress and future prospects in the different stroke areas.
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Affiliation(s)
- A John Camm
- Division of Cardiac and Vascular Sciences, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,University of Oslo, Oslo, Norway
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49
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Kreutz R, Camm AJ, Rossing P. Concomitant diabetes with atrial fibrillation and anticoagulation management considerations. Eur Heart J Suppl 2021; 22:O78-O86. [PMID: 33380946 PMCID: PMC7753879 DOI: 10.1093/eurheartj/suaa182] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Atrial fibrillation is a highly prevalent cardiac arrhythmia. It is associated with numerous co mobilities. Approximately 30% of diabetic patients have atrial fibrillation and 15% of atrial fibrillation regulation patients have diabetes mellitus. Diabetes increases the likelihood of the development of atrial fibrillation and contributes to the high risk of thromboembolism seen in patients with both diabetes and atrial fibrillation. Chronic kidney disease is often a consequence of diabetes and presents an additional challenge to the management of patients with both atrial fibrillation and diabetes. All non-vitamin K oral anticoagulants are partially eliminated via the kidney and must be carefully prescribed according to strict dosing schedules to avoid anticoagulation overdose. However, NOACs have the advantage of being associated with less progressive impairment of renal function compared with vitamin K antagonist therapy in both diabetics and non-diabetics. Otherwise, diabetic patients benefit from NOAC therapy as opposed to vitamin K antagonists to a similar extent as patients without diabetes. This review deals with anticoagulation treatment in patients with fibrillation and diabetes mellitus, often complicated by progressive renal impairment.
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Affiliation(s)
- Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
| | - A John Camm
- Cardiac Clinical Academic Group, St George's University of London, Cranmer Terrace, London SW19 0RE, UK
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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50
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Chashkina MI, Andreev DA, Kozlovskaya NL, Salpagarova ZK, Suvorov AY, Suchkova SA, Bykova AA, Syrkin AL. [Safety performance of rivaroxaban versus warfarin in patients with atrial fibrillation and advanced chro-nic kidney disease]. KARDIOLOGIIA 2020; 60:1322. [PMID: 33487155 DOI: 10.18087/cardio.2020.11.n1322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/23/2020] [Accepted: 10/06/2020] [Indexed: 06/12/2023]
Abstract
Aim To evaluate safety of using rivaroxaban in patients with stage 4 chronic kidney disease (CKD) or transient, stable decline of glomerular filtration rate (GFR) to 15-29 ml /min / 1.73 m2 in the presence of atrial fibrillation (AF).Material and methods This multicenter prospective, randomized study included patients admitted to cardiology departments from 2017 through 2019. Of 10 224 admitted patients 109 (3 %) patients with AF and stage 4 CKD or a stable decline of GFR to 15-29 ml /min / 1.73 m2 were randomized at 2:1 ratio to the rivaroxaban 15 mg /day (n=73) treatment group or to the warfarin treatment group (n=36). The primary endpoint was development of BARC and ISTH major, minor, and clinically relevant minor bleeding. Mean follow-up duration was 18 months.Results Patients receiving warfarin had a significantly higher incidence of BARC (n=26 (72.2 %) vs. n=31 (42.4 %), р<0.01) and ISTH (n=22 (61.1 %) vs. n=27 (36.9 %), p<0.01) minor bleeding and all ISTH clinically relevant (minor clinically relevant and major bleedings) n=10 (27.7 %) vs. n=8 (10.9 %), р=0.03]. The number of repeated hospitalizations was 65 (43% of patients) in the rivaroxaban treatment group and 27 (48% of patients) in the warfarin treatment group (р=0.57), including 24 (36.9 %) and 11 (40.7 %) emergency admissions in the rivaroxaban and warfarin treatment groups, respectively (р=0.96). Significant improvement of changes in creatinine clearance and GFR (by CKD-EPI and Cockroft-Gault) was observed in the rivaroxaban treatment group.Conclusion The study provided evidence for a more beneficial safety profile of rivaroxaban compared to warfarin in patients with AF and advanced CKD.
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Affiliation(s)
- M I Chashkina
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - D A Andreev
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - N L Kozlovskaya
- City Clinical Hospital. A.K. Eramishantseva, Department of Health of Moscow, Russia Peoples' Friendship University of Russia (RUDN University), Moscow, Russia
| | - Z K Salpagarova
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - A Yu Suvorov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - S A Suchkova
- Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University)
| | - A A Bykova
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - A L Syrkin
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
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