Effect of anticoagulation therapy in older patients with chronic kidney disease and atrial fibrillation: A meta-analysis

The progress of percutaneous left atrial appendage occlusion: A bibliometric analysis from 1994 to 2022

BACKGROUND

Atrial fibrillation is the most common cardiac arrhythmia, affecting 32 million individuals worldwide. Although atrial fibrillation has been studied for decades, a comprehensive analysis using bibliometrics has not been performed for atrial fibrillation-left atrial appendage occlusion (LAAO). Therefore, we analyzed the scientific outputs of global LAAO research and explored the current research status and hotpots from 1994 to 2022.

METHODS

We searched the Web of Science core collection for publications related to LAAO that were published between 1994 and 2022. We then performed bibliometric analysis and visualization using Microsoft Excel 2021, Bibliometric (https://bibliometric.com), VOSviewer (version 1.6.19), CiteSpace (version 6.2. R2), and the Bibliometrix 4.0.0 Package (https://www.bibliometrix.org) based on the R language were used to perform the bibliometric analysis, trend and emerging foci of LAAO in the past 29 years, including author, country, institution, journal distribution, article citations, and keywords. In total, we identified 1285 eligible publications in the field of LAAO, with an increasing trend in the annual number of publications.

RESULTS

The United States is the country with the most published articles in this field, while the United Kingdom is the country with the most cited literature. Mayo Clinic, from the United States, has the most publications in this area and Horst Sievert from Germany had the highest number of individual publications. The analysis of keywords showed that fibrillation, stroke, safety, oral anticoagulants, and watchman were the main hotpots and frontier directions of LAAO. Surgical treatment of nonvalvular atrial fibrillation, upgrading of related surgical instruments, and anticoagulation regimen after surgical treatment are the major research frontiers.

CONCLUSION

We show that the research of percutaneous LAAO has been increasing rapidly over the last decade. Our aim was to overview past studies in the field of LAAO, to grasp the frame of LAAO research, and identify new perspectives for future research.

Atrial Fibrillation Ablation in Patients With Chronic Kidney Disease: A Review of Literature

Atrial fibrillation (AF) is a common arrhythmia among patients with chronic kidney disease (CKD), which leads to increased cardiovascular complications. Catheter ablation (CA) has emerged as an effective and safe treatment for AF in CKD patients. CA offers tailored treatment strategies and presents a safer alternative with fewer adverse outcomes than anti-arrhythmic agents. Although CKD patients undergoing ablation have similar complication rates to non-CKD patients, they face a higher risk of hospitalization due to heart failure. Furthermore, CA shows promise in improving kidney function, particularly in individuals who maintain sinus rhythm. Future research should address limitations by including advanced CKD patients, conducting longer-term follow-ups, and developing individualized treatment approaches.

Oral Anticoagulation in Patients With Advanced Chronic Kidney Disease and Atrial Fibrillation: Beyond Anticoagulation

The optimal approach to prevent stroke and systemic embolism in patients with advanced chronic kidney disease (CKD) and atrial fibrillation remains unresolved. We conducted a narrative review to explore areas of uncertainty and opportunities for future research. First, the relationship between atrial fibrillation and stroke is more complex in patients with advanced CKD than in the general population. The currently employed risk stratification tools do not adequately discriminate between patients deriving a net benefit and those suffering a net harm from oral anticoagulation. Anticoagulation initiation should probably be more restrictive than is currently advocated by official guidelines. Recent evidence reveals that the superior benefit-risk profile of non-vitamin K antagonist oral anticoagulants (NOACs) vs vitamin K antagonists (VKAs) observed in the general population and in moderate CKD can be extended to advanced CKD. The NOACs yield better protection against stroke, cause less major bleeding, are associated with less acute kidney injury and a slower decline of CKD, and are associated with a lower incidence of cardiovascular events than VKAs. The VKAs may be harmful in CKD patients, in particular in patients with a high bleeding risk and labile international normalized ratio. The better safety and efficacy of NOACs as opposed to VKAs may be particularly evident in advanced CKD as a result of better on-target anticoagulation with NOACs, harmful off-target vascular effects of VKAs, and beneficial off-target vascular effects of NOACs. The intrinsic vasculoprotective effects of NOACs are supported by animal experimental evidence as well as by findings of large clinical trials and may result in use of NOACs beyond their anticoagulant properties.

Left Atrial Appendage Closure: An Alternative to Anticoagulation for Stroke Prevention in Patients with Kidney Disease

Anticoagulation to reduce thromboembolic stroke risk due to nonvalvular atrial fibrillation in ESKD is associated with increased bleeding. There is an existing debate in ESKD centers around the pros and cons of anticoagulation. We propose percutaneous left atrial appendage occlusion as a third alternative to balance thrombosis and bleeding risks in this high-risk population.

Does Chronic Kidney Disease Have an Impact on the Use of Oral Anticoagulants after Stroke? An Observational Follow-Up Study

INTRODUCTION

Chronic kidney disease is common in patients with acute ischemic stroke. We investigated whether chronic kidney disease has an impact on anticoagulation treatment recommendations after ischemic stroke or transient ischemic attack (TIA) related with atrial fibrillation (AF).

MATERIALS AND METHODS

We extracted treatment-related data concerning stroke/TIA patients with AF and available estimated glomerular filtration rates (eGFR) from a monocentric prospective German stroke registry. Chronic kidney disease was defined as eGFR <60 mL/min/1.73 m2. Using uni- and multivariate logistic regression analyses, we investigated whether chronic kidney disease was associated with a lower probability to be treated with anticoagulation early after stroke.

RESULTS

A total of 273 patients entered the analysis. In 242 AF patients (88.6%), oral anticoagulation was recommended after stroke. In multivariate logistic regression analysis, chronic kidney disease was not identified as an independent factor for the decision against anticoagulation (OR 1.63, 95% CI: 0.50-5.31, p = 0.421); only increasing age (OR 1.10, 95% CI: 1.00-1.21, p = 0.061) and a modified Rankin Scale >3 at discharge (OR 3.41, 95% CI: 0.88-13.24, p = 0.077) showed a nonsignificant trend for the decision to omit anticoagulation. A total of 155 of 167 patients (92.8%) were still anticoagulated at follow-up. A total of 44 patients with chronic kidney disease completed follow-up, and of those, 37 were still anticoagulated (84%). In patients without chronic kidney disease, 118/167 (70.7%) had continued anticoagulation (p = 0.310).

CONCLUSION

Our results show that chronic kidney disease was not the main factor in the decision to withhold oral anticoagulation in patients with recent stroke/TIA and AF.

Renal Disease and Atrial Fibrillation

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

Analysis of the F2LR3 (PAR4) Single Nucleotide Polymorphism (rs773902) in an Indigenous Australian Population

The F2RL3 gene encoding protease activated receptor 4 (PAR4) contains a single nucleotide variant, rs773902, that is functional. The resulting PAR4 variants, Thr120, and Ala120, are known to differently affect platelet reactivity to thrombin. Significant population differences in the frequency of the allele indicate it may be an important determinant in the ethnic differences that exist in thrombosis and hemostasis, and for patient outcomes to PAR antagonist anti-platelet therapies. Here we determined the frequency of rs773902 in an Indigenous Australian group comprising 467 individuals from the Tiwi Islands. These people experience high rates of renal disease that may be related to platelet and PAR4 function and are potential recipients of PAR-antagonist treatments. The rs773902 minor allele frequency (Thr120) in the Tiwi Islanders was 0.32, which is similar to European and Asian groups and substantially lower than Melanesians and some African groups. Logistic regression and allele distortion testing revealed no significant associations between the variant and several markers of renal function, as well as blood glucose and blood pressure. These findings suggest that rs773902 is not an important determinant for renal disease in this Indigenous Australian group. However, the relationships between rs773902 genotype and platelet and drug responsiveness in the Tiwi, and the allele frequency in other Indigenous Australian groups should be evaluated.