1
|
Stamellou E, Noels H, Floege J. Factor XI inhibition in hemodialysis patients: the safer anticoagulation? Kidney Int 2024; 106:21-23. [PMID: 38906653 DOI: 10.1016/j.kint.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 03/22/2024] [Accepted: 03/29/2024] [Indexed: 06/23/2024]
Abstract
Chronic hemodialysis patients exhibit an excessive cardiovascular risk and a marked increase in both thromboembolism and bleeding episodes. Factor XI inhibition may provide anticoagulation, with a low risk of bleeding, and several factor XI inhibitors, including fesomersen, an antisense oligonucleotide, are under development. Recently, a phase 2 study of fesomersen showed a good safety profile in chronic hemodialysis patients and suggested that clotting rates of the arteriovenous fistula and the dialysis circuit are lower.
Collapse
Affiliation(s)
- Eleni Stamellou
- Department of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece; Division of Nephrology and Rheumatology, Rheinisch Westfälische Technische Hochschule (RWTH) University of Aachen, Aachen, Germany
| | - Heidi Noels
- Institute for Molecular Cardiovascular Research (IMCAR), RWTH University of Aachen, Aachen, Germany; Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Jürgen Floege
- Division of Nephrology and Rheumatology, Rheinisch Westfälische Technische Hochschule (RWTH) University of Aachen, Aachen, Germany; Division of Cardiology, RWTH University of Aachen, Aachen, Germany.
| |
Collapse
|
2
|
Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 268] [Impact Index Per Article: 268.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
Collapse
|
4
|
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, Beyer-Westendorf J. Risk Profiles and Treatment Patterns in Atrial Fibrillation Patients with Chronic Kidney Disease Receiving or not Receiving Anticoagulation Therapy. TH OPEN 2024; 8:e106-e113. [PMID: 38406259 PMCID: PMC10890905 DOI: 10.1055/s-0044-1780529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 12/21/2023] [Indexed: 02/27/2024] Open
Abstract
Background Patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are at high risk for both thromboembolism and bleeding events. The latter induces a potential reason for withholding oral anticoagulation (OAC) despite an indication for prophylaxis of thromboembolic events. Methods AF patients with CKD (estimated glomerular filtration [eGFR] rate between 15 and 49 mL/min per 1.73 m 2 ) were included in a prospective international registry in Europe between 2016 and 2020, that is, XARENO (factor XA inhibition in renal patients with nonvalvular atrial fibrillation observational registry). The study enrolled adult patients treated at the discretion of physicians with rivaroxaban, vitamin K antagonists (VKA), or without OAC (w/oOAC). Here, we report a prespecified explorative baseline comparison between patients receiving OAC or no OAC within XARENO. Results In total, 1,544 patients (mean age: 78.2 years, mean eGFR: 36.2 mL/min) were studied (rivaroxaban n = 764, VKA n = 691, w/oOAC n = 89). Patients in the w/oOAC group were older and had a similar stroke (mean CHA 2 DS 2 -VASc score 4.0) but higher bleeding risk (mean modified Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly score 2.5 vs. 1.8) compared with the OAC groups. The distribution of comorbidities including hypertension, diabetes, and heart failure was similar. Treatment with antiplatelet drugs was fivefold more frequent in the w/oOAC group. Conclusion Only 5.8% of the overall population of AF patients with advanced CKD received no OAC. These patients were older and had a higher bleeding risk, which might explain this decision, but which contrasts with the more frequent use of antiplatelet drugs in this vulnerable group of patients.
Collapse
Affiliation(s)
- Reinhold Kreutz
- Institute of Clinical Pharmacology and Toxicology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Gilbert Deray
- Department of Nephrology, Pitié-Salpêtrière Hospital, Paris 6 University, 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
- Center for Neurology and Rehabilitation, Klinik für Neurologie, Universitätsspital Zürich, Switzerland and Cereneo, Vitznau, Switzerland
| | - Pontus Persson
- Institut für Vegetative Physiologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | - Juerg Hans Beer
- Department Innere Medizin, Baden Switzerland and Center of Molecular Cardiology, Kantonsspital Baden, 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
| | | | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division Haematology, Department of Medicine I, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| |
Collapse
|
5
|
Lim TW, Camm AJ, Virdone S, Singer DE, Bassand JP, Fonarow GC, Fox KAA, Ezekowitz M, Gersh BJ, Kayani G, Hylek EM, Kakkar AK, Mahaffey KW, Pieper KS, Peterson ED, Piccini JP. Predictors of intracranial hemorrhage in patients with atrial fibrillation treated with oral anticoagulants: Insights from the GARFIELD-AF and ORBIT-AF registries. Clin Cardiol 2023; 46:1398-1407. [PMID: 37596725 PMCID: PMC10642328 DOI: 10.1002/clc.24109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND An unmet need exists to reliably predict the risk of intracranial hemorrhage (ICH) in patients with atrial fibrillation (AF) treated with oral anticoagulants (OACs). HYPOTHESIS An externally validated model improves ICH risk stratification. METHODS Independent factors associated with ICH were identified by Cox proportional hazard modeling, using pooled data from the GARFIELD-AF (Global Anticoagulant Registry in the FIELD-Atrial Fibrillation) and ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation) registries. A predictive model was developed and validated by bootstrap sampling and by independent data from the Danish National Patient Register. RESULTS In the combined training data set, 284 of 53 878 anticoagulated patients had ICH over a 2-year period (0.31 per 100 person-years; 95% confidence interval [CI]: 0.28-0.35). Independent predictors of ICH included: older age, prior stroke or transient ischemic attack, concomitant antiplatelet (AP) use, and moderate-to-severe chronic kidney disease (CKD). Vitamin K antagonists (VKAs) were associated with a significantly higher risk of ICH compared with non-VKA oral anticoagulants (NOACs) (adjusted hazard ratio: 1.61; 95% CI: 1.25-2.08; p = .0002). The ability of the model to discriminate individuals in the training set with and without ICH was fair (optimism-corrected C-statistic: 0.68; 95% CI: 0.65-0.71) and outperformed three previously published methods. Calibration between predicted and observed ICH probabilities was good in both training and validation data sets. CONCLUSIONS Age, prior ischemic events, concomitant AP therapy, and CKD were important risk factors for ICH in anticoagulated AF patients. Moreover, ICH was more frequent in patients receiving VKA compared to NOAC. The new validated model is a step toward mitigating this potentially lethal complication.
Collapse
Affiliation(s)
- Toon Wei Lim
- National Heart CentreSingaporeSingapore
- National University HospitalSingaporeSingapore
| | - Alan John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences InstituteSt. George's University of LondonLondonUK
| | | | - Daniel E. Singer
- Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Jean P. Bassand
- Thrombosis Research InstituteLondonUK
- Department of CardiologyUniversity of BesançonBesançonFrance
| | | | - Keith A. A. Fox
- Department of Cardiovascular ScienceCentre for Cardiovascular Science, University of EdinburghEdinburghUK
| | - Michael Ezekowitz
- Sidney Kimmel Medical SchoolThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Bernard J. Gersh
- Mayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | | | - Elaine M. Hylek
- Department of MedicineBoston University School of MedicineBostonMassachusettsUSA
| | - Ajay K. Kakkar
- Thrombosis Research InstituteLondonUK
- Department of SurgeryUniversity College LondonLondonUK
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical ResearchStanford School of MedicineStanfordCaliforniaUSA
| | - Karen S. Pieper
- Thrombosis Research InstituteLondonUK
- Department of Cardiac ElectrophysiologyDuke Clinical Research InstituteDurhamNorth CarolinaUSA
| | - Eric D. Peterson
- Department of Cardiac ElectrophysiologyDuke Clinical Research InstituteDurhamNorth CarolinaUSA
- Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Jonathan P. Piccini
- Department of Cardiac ElectrophysiologyDuke Clinical Research InstituteDurhamNorth CarolinaUSA
- Duke University School of MedicineDurhamNorth CarolinaUSA
| | | |
Collapse
|
6
|
Welander F, Renlund H, Dimény E, Holmberg H, Själander A. Warfarin treatment quality and outcomes in patients with non-valvular atrial fibrillation and CKD G3-G5D. Thromb Res 2023; 229:131-138. [PMID: 37453255 DOI: 10.1016/j.thromres.2023.07.003] [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: 02/06/2023] [Revised: 07/02/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Warfarin treatment quality is calculated as time in therapeutic range (TTR). TTR ≥ 70 % is considered reducing the risk of adverse events for patients with atrial fibrillation (AF). The association of TTR and adverse events in chronic kidney disease (CKD) is however poorly investigated. The aim is to explore this further. MATERIALS AND METHODS Swedish cohort study based on national healthcare registers between 2009 and 2018, including Swedish Renal Registry, Swedish Stroke Register and AuriculA - the Swedish national quality register for AF and anticoagulation. Investigating the effect of individual TTR (iTTR) and iTTR ≥ 70 % versus <70 % on the risk of ischemic stroke, major bleeding and death for patients with CKD GFR category 3-5 (G3-G5) including patients on dialysis (G5D) and non-valvular AF (NVAF). RESULTS Of 2379 included patients 21.9 % had G3, 47.5 % G4, 10.8 % G5 and 19.8 % G5D. TTR in G3 was 75.6 %, G4 72.2 %, G5 67.6 % and G5D 62.0 %. Increase by 10 percentage points iTTR conferred lower risk of major bleeding, ischemic stroke and death for all patients (hazard ratio 0.91 (95 % Confidence interval 0.87-0.94), 0.92 (0.85-0.99) and 0.88 (0.85-0.90)). iTTR≥ 70 % versus <70 % was associated with lower risk of bleeding and death in all patients (0.63 (0.51-0.77) and (0.51 (0.43-0.61)), and a non-significant tendency towards lower stroke risk (0.67 (0.43-1.06)). CONCLUSIONS Warfarin treatment quality worsens with decreasing GFR. Higher iTTR confers lower risk of bleeding, ischemic stroke and death in patients with NVAF and G3-G5D. iTTR ≥ 70 % was associated with better safety profile. Close monitoring of patients with CKD on warfarin is recommended.
Collapse
Affiliation(s)
- Frida Welander
- Department of Public Health and Clinical Medicine, Department of Research and Development-Sundsvall, Umeå University, Lasarettsvägen 21, S-85643 Sundsvall, Sweden.
| | - Henrik Renlund
- Uppsala Clinical Research Centre, Uppsala University, Uppsala Science Park, Hubben, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden
| | - Emöke Dimény
- Department of Public Health and Clinical medicine, Umeå University, 901 87 Umeå, Sweden
| | - Henrik Holmberg
- Department of Epidemiology and Global Health, Umeå University, 901 87 Umeå, Sweden
| | - Anders Själander
- Department of Epidemiology and Global Health, Umeå University, 901 87 Umeå, Sweden
| |
Collapse
|