1
|
Mandt SR, Thadathil N, Klem C, Russ C, McNamee PL, Stigge K, Cheng D. Apixaban Use in Patients with Kidney Impairment: A Review of Pharmacokinetic, Interventional, and Observational Study Data. Am J Cardiovasc Drugs 2024; 24:603-624. [PMID: 39102124 PMCID: PMC11344734 DOI: 10.1007/s40256-024-00664-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2024] [Indexed: 08/06/2024]
Abstract
Chronic kidney disease (CKD) remains a significant global health issue and is a leading cause of mortality worldwide. Patients with CKD have an increased risk of developing atrial fibrillation (AF) and venous thromboembolism (VTE). While direct oral anticoagulants (DOACs) have become a standard of care for anticoagulation (AC) in patients with AF and VTE, the appropriate use of these agents in comorbid kidney impairment warrants detailed discussion. This scientific narrative review summarizes the effectiveness and safety of apixaban use in patients with renal dysfunction by assessing the current published pharmacokinetic, interventional, observational, and guideline data. Apixaban is a highly selective, orally active, direct inhibitor of factor Xa, with well-established pharmacokinetics and consistent clinical outcomes across a broad range of patient populations, including those with kidney impairment. Overall, the scientific literature has shown that apixaban has a favorable clinical efficacy and safety profile compared with vitamin K antagonists for patients with AF or VTE and comorbid kidney impairment. These data support the approved label dosing strategy of apixaban in reducing the risk of stroke/systemic embolism in patients with nonvalvular AF and in treating VTE across all ranges of kidney function. Both clinician experience and knowledge of patient-specific factors may be required in the management of comorbid patients with advanced CKD or those requiring dialysis, as data on these patients are limited.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Dong Cheng
- Bristol Myers Squibb, Lawrenceville, NJ, USA
| |
Collapse
|
2
|
Montomoli M, Candía BG, Barrios AA, Bernat EP. Anticoagulation in Chronic Kidney Disease. Drugs 2024:10.1007/s40265-024-02077-6. [PMID: 39120783 DOI: 10.1007/s40265-024-02077-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2024] [Indexed: 08/10/2024]
Abstract
The nuanced landscape of anticoagulation therapy in patients with chronic kidney disease (CKD) presents a formidable challenge, intricately balancing the dual hazards of hemorrhage and thrombosis. These patients find themselves in a precarious position, teetering on the edge of these risks due to compromised platelet functionality and systemic disturbances within their coagulation frameworks. The management of such patients necessitates a meticulous approach to dosing adjustments and vigilant monitoring to navigate the perilous waters of anticoagulant therapy. This is especially critical considering the altered pharmacokinetics in CKD, where the clearance of drugs is significantly impeded, heightening the risk of accumulation and adverse effects. In the evolving narrative of anticoagulation therapy, the introduction of direct oral anticoagulants (DOACs) has heralded a new era, offering a glimmer of hope for those navigating the complexities of CKD. These agents, with their promise of easier management and a reduced need for monitoring, have begun to reshape the contours of care, particularly for patients not yet on dialysis. However, this is not without its caveats. The application of DOACs in the context of advanced CKD remains a largely uncharted territory, necessitating a cautious exploration to unearth their true potential and limitations. Moreover, the advent of innovative strategies such as left atrial appendage occlusion (LAAO) underscores the dynamic nature of anticoagulation therapy, potentially offering a tailored solution for those at the intersection of CKD and elevated stroke risk. Yet the journey toward integrating such advancements into standard practice is laden with unanswered questions, demanding rigorous investigation to illuminate their efficacy and safety across the spectrum of kidney disease. In summary, the management of anticoagulation in CKD is a delicate dance, requiring a harmonious blend of precision, caution, and innovation. As we venture further into this complex domain, we must build upon our current understanding, embracing both emerging therapies and the need for ongoing research. Only then can we hope to offer our patients a path that navigates the narrow strait between bleeding and clotting, toward safer and more effective care.
Collapse
Affiliation(s)
- Marco Montomoli
- Nephrology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain.
| | | | | | | |
Collapse
|
3
|
Cohen M, Spyropoulos AC, Goodman SG, Spinler SA, Bonaca MP, Redling TM, Visveswaran G, Sohal S. Rivaroxaban Versus Apixaban: A Comparison Without a Simple Solution. Mayo Clin Proc Innov Qual Outcomes 2024; 8:321-328. [PMID: 38974528 PMCID: PMC11223068 DOI: 10.1016/j.mayocpiqo.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Affiliation(s)
- Marc Cohen
- Department of Medicine, Newark Beth Israel Medical Center, Newark, NJ
- Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ
| | - Alex C. Spyropoulos
- Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
- Institute of Health System Science, The Feinstein Institutes for Medical Research, New York, NY
| | - Shaun G. Goodman
- Division of Cardiology, Department of Medicine, St. Michael’s Hospital Professor and Heart & Stroke Foundation of Ontario (Polo), Toronto, Ontario, Canada
- Department of Medicine, University of Toronto Consultant, Ontario, Canada
- Canadian Heart Research Centre, Canadian VIGOUR Centre Ontario, Canada
| | - Sarah A. Spinler
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, NY
| | - Marc P. Bonaca
- Division of Cardiology and Vascular Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Theresa M. Redling
- Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ
- Division of Geriatric Health and Disease Management, Cooperman Barnabas Medical Center Maida Geriatric Institute, Livingston, NJ
| | - Gautam Visveswaran
- Division of Cardiology, Department of Medicine, Newark Beth Israel Medical Center, Newark, NJ
- Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ
| | - Sumit Sohal
- Division of Cardiology, Department of Medicine, Yale New Haven Hospital, New Haven, CT
| |
Collapse
|
4
|
Heleniak Z, Matusik PT, Undas A. Altered fibrin clot properties are associated with the progression of chronic kidney disease in atrial fibrillation. Thromb Res 2024; 236:14-21. [PMID: 38387299 DOI: 10.1016/j.thromres.2024.02.018] [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: 10/11/2023] [Revised: 02/05/2024] [Accepted: 02/15/2024] [Indexed: 02/24/2024]
Abstract
INTRODUCTION Formation of denser and resistant to lysis fibrin clot networks has been shown in chronic kidney disease (CKD) and atrial fibrillation (AF). We investigated whether such prothrombotic fibrin clot properties are associated with faster progression of CKD in AF patients. MATERIAL AND METHODS We recruited 265 AF patients (men 49.1 %, median age of 64.0 years, median estimated glomerular filtration rate [eGFR] of 77.0 ml/min/1.73 m2), including 137 patients on non-vitamin K antagonist oral anticoagulants (NOACs) (51.7 %) and 109 patients (41.1 %) on vitamin K antagonists (VKAs). At baseline while off anticoagulation, we determined fibrin clot permeability (Ks), and clot lysis time (CLT), along with plasminogen activator inhibitor-1 (PAI-1), endogenous thrombin potential (ETP), and von Willebrand factor (vWF). The kidney function was assessed at baseline and after a median follow-up of 50.0 months. RESULTS During follow-up, a median eGFR decreased by 8.0 (5.0-11.0) ml/min/1.73 m2, 1.8 ml/min/1.73 m2/year and this change correlated with age (R = 0.19, P = 0.002), Ks (R = 0.46, P < 0.0001), and CLT (R = -0.17, P = 0.005), but not ETP, fibrinogen, PAI-1 or vWF. A decrease in eGFR was lower in patients who used NOACs at baseline but not in those who started NOACs during follow-up (n = 101) as compared to the remaining patients. On multiple linear regression analysis, adjusted for age and fibrinogen, baseline Ks, eGFR, hypertension, and NOACs use independently predicted a decrease in eGFR. CONCLUSIONS This study is the first to show that more compact fibrin clot networks may contribute to faster progression of CKD in AF, indicating novel kidney-related harmful effects of prothrombotic clot properties in humans.
Collapse
Affiliation(s)
- Zbigniew Heleniak
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdansk, Gdańsk, Poland
| | - Paweł T Matusik
- St. John Paul II Hospital, Kraków, Poland; Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Anetta Undas
- St. John Paul II Hospital, Kraków, Poland; Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland.
| |
Collapse
|
5
|
Wing SL, Mavrakanas TA, Harel Z. Oral Anticoagulation Use in Individuals With Atrial Fibrillation and Chronic Kidney Disease: A Review. Semin Nephrol 2024; 44:151517. [PMID: 38744617 DOI: 10.1016/j.semnephrol.2024.151517] [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] [Indexed: 05/16/2024]
Abstract
Atrial fibrillation (AF) is highly prevalent in patients with chronic kidney disease (CKD). It is associated with an increased risk of stroke, which increases as kidney function declines. In the general population and in those with a moderate degree of CKD (creatinine clearance 30-50 mL/min), the use of oral anticoagulation to decrease the risk of stroke has been the standard of care based on a favorable risk-benefit profile that had been established in seminal randomized controlled trials. However, evidence regarding the use of oral anticoagulants for stroke prevention is less clear in patients with severe CKD (creatinine clearance <30 mL/min) and those receiving maintenance dialysis, as these individuals were excluded from such large randomized controlled trials. Nevertheless, the direct oral anticoagulants have invariably usurped vitamin K antagonists as the preferred choice for oral anticoagulation among patients with AF across all strata of CKD based on their well-defined safety and efficacy and multiple pharmacokinetic benefits (e.g., less drug-drug interactions). This review summarizes the current literature on the role of oral anticoagulation in the management of AF among patients with CKD and highlights current deficiencies in the evidence base and how to overcome them.
Collapse
Affiliation(s)
- Sara L Wing
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Thomas A Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Canada
| | - Ziv Harel
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada.
| |
Collapse
|
6
|
Kessler A, Kolben Y, Puris G, Ellis M, Alperin M, Simovich V, Lerman Shivek H, Muszkat M, Maaravi Y, Biton Y. Direct Oral Anticoagulants in Special Patient Populations. J Clin Med 2023; 13:216. [PMID: 38202223 PMCID: PMC10779957 DOI: 10.3390/jcm13010216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/25/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
Anticoagulants are a cornerstone of treatment in atrial fibrillation. Nowadays, direct oral anticoagulants (DOACs) are extensively used for this condition in developed countries. However, DOAC treatment may be inappropriate in certain patient populations, such as: patients with chronic kidney disease in whom DOAC concentrations may be dangerously elevated; frail elderly patients with an increased risk of falls; patients with significant drug-drug interactions (DDI) affecting either DOAC concentration or effect; patients at the extremes of body mass in whom an "abnormal" volume of distribution may result in inappropriate drug concentrations; patients with recurrent stroke reflecting an unusually high thromboembolic tendency; and, lastly, patients who experience major hemorrhage on an anticoagulant and in whom continued anticoagulation is deemed necessary. Herein we provide a fictional case-based approach to review the recommendations for the use of DOACs in these special patient populations.
Collapse
Affiliation(s)
- Asa Kessler
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel; (A.K.); (Y.K.)
| | - Yotam Kolben
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel; (A.K.); (Y.K.)
| | - Gal Puris
- Faculty of Medicine, Institute for Research in Military Medicine, Hebrew University of Jerusalem, Israel Defense Force Medical Corps, Jerusalem 9112002, Israel;
| | - Martin Ellis
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba 4428164, Israel;
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Mordechai Alperin
- Department of Family Medicine, The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel;
- Clalit Health Services, Haifa and Western Galilee District, Tel Aviv 6209804, Israel
| | | | - Hila Lerman Shivek
- Hospital Pharmacy Department, Hospitals Division, Clalit Health Services, Tel Aviv 6209804, Israel;
- Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel
| | - Mordechai Muszkat
- Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Mt. Scopus, Jerusalem 9112002, Israel;
| | - Yoram Maaravi
- The Jerusalem Institute of Aging Research, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel;
- Department of Geriatrics and Rehabilitation and the Center for Palliative Care, Hadassah Medical Center, Jerusalem 9371125, Israel
| | - Yitschak Biton
- Heart Institute, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel; (A.K.); (Y.K.)
| |
Collapse
|
7
|
Kang MK, Lee D, Oh MS, Lee JS, Jeong HY, Shin JH, Yoon BW, Park JM. Association of high-estimated glomerular filtration rate with the severity of ischemic stroke during non-vitamin K antagonist oral anticoagulants therapy: a nationwide cohort study. Front Neurol 2023; 14:1277855. [PMID: 38107638 PMCID: PMC10722199 DOI: 10.3389/fneur.2023.1277855] [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: 08/15/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023] Open
Abstract
Aim While the relationship between impaired kidney function and non-vitamin K antagonist oral anticoagulants (NOACs) is well established, there is limited research exploring the association between an elevated estimated glomerular filtration rate (eGFR) and the efficacy of NOACs, especially concerning the outcomes of acute ischemic stroke (AIS). This study aimed to examine the association between higher-than-normal eGFR and the severity of AIS during the use of NOACs using a nationwide multicenter stroke registry in Korea. Material and methods This study utilized data from the Korean Stroke Registry (KSR) database, examining information from 2,379 patients with AIS, who had atrial fibrillation (AF) and a history of utilizing NOACs prior to hospitalization due to incident stroke occurring between 2016 and 2021. Patients with a history involving two or more types of anticoagulants or one or more forms of antiplatelet agents were excluded. Baseline characteristics, medical history, medication usage, CHADS2-VASc score, and the anticoagulation and risk factors in atrial fibrillation (ATRIA) score were evaluated. Renal function was assessed using eGFR levels and calculated with the Cockcroft-Gault equation. The severity of stroke was measured by the National Institutes of Health Stroke Scale as an outcome. For sensitivity analysis, further evaluation was performed using eGFR levels according to the modification of diet in renal disease (MDRD) study equation. Results The mean age of subjects was 76.1 ± 8.9 years. The moderate-to-severe stroke severity group exhibited an elevation in creatinine levels. The eGFR of 60 to 89 mL/min/1.73 m2 group was associated with a decreased risk of moderate-to-severe stroke severity [hazard ratio (HR)] (0.77, 95% confidence interval (CI) [0.61, 0.98], p = 0.031) compared to the eGFR≥90 mL/min/1.73 m2 group. An increment of 10 units in eGFR was marginally associated with an increased risk of moderate-to-severe stroke severity (HR: 1.03, 95% CI [1.00, 1.07], p = 0.054). Conclusion The study revealed that individuals with eGFR ≥ 90 mL/min/1.73 m2 had an association linked to an increased risk of moderate-to-severe stroke severity. Our study suggests that patients taking NOACs with higher-than-normal eGFR levels may have an increased severity of AIS.
Collapse
Affiliation(s)
- Min Kyoung Kang
- Department of Neurology, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
- Department of Neurology, Uijeongbu Eulji Medical Center, Gyeonggi, Republic of Korea
| | - Dongwhane Lee
- Department of Neurology, Uijeongbu Eulji Medical Center, Gyeonggi, Republic of Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi, Republic of Korea
| | - Ji-Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Seoul, Republic of Korea
| | - Han-Yeong Jeong
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jung Hwan Shin
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Byung-Woo Yoon
- Department of Neurology, Uijeongbu Eulji Medical Center, Gyeonggi, Republic of Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Gyeonggi, Republic of Korea
| |
Collapse
|
8
|
Huang Y, Schaff HV, Swarna KS, Sangaralingham LR, Nishimura RA, Dearani JA, Crestanello JA, Greason KL. Benefit of Anticoagulation Early After Surgical Aortic Valve Replacement Using Bioprosthetic Valves. Mayo Clin Proc 2023; 98:1797-1808. [PMID: 38043997 DOI: 10.1016/j.mayocp.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 08/01/2023] [Accepted: 08/08/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVE To compare all-cause mortality and thromboembolic events in patients undergoing surgical aortic valve replacement (sAVR) receiving anticoagulation with warfarin versus patients with no systemic anticoagulation. PATIENTS AND METHODS Using data from the OptumLabs Data Warehouse, we investigated adult patients having bioprosthetic sAVR with or without coronary artery bypass from January 1, 2007, through December 31, 2019. Patients were classified into groups of nonwarfarin or warfarin (≥30 days of continuous prescription coverage after sAVR). One-to-one propensity score (PS) matching was used to adjust for group differences. RESULTS Of 10,589 patients having sAVR, 7659 (72.3%) were in the nonwarfarin group and 2930 (27.7%) were in the warfarin group. After PS matching, 2930 pairs of patients were analyzed. Median follow-up was 4.1 months (interquartile range [IQR], 2.6-7.4 months) for the warfarin group and 21.3 months (IQR, 7.8-24.0 months) for the nonwarfarin group. Overall mortality was lower for the warfarin group than for the nonwarfarin group (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.47 to 1.00; P=.047), and there was a trend toward decreased cumulative incidence of thromboembolic events (subdistribution HR [SHR], 0.62; 95% CI, 0.35 to 1.07; P=.09). Cumulative incidence of major bleeding events was higher for the warfarin group vs the nonwarfarin group (SHR, 1.94; 95% CI, 1.28 to 2.94; P=.002). Results were similar in a subgroup analysis of patients undergoing isolated sAVR. CONCLUSION During the prescription coverage period, warfarin use after bioprosthetic sAVR was associated with lower all-cause mortality and decreased risk of thromboembolism compared with not receiving warfarin. However, warfarin use was associated with an increased risk of major bleeding events.
Collapse
Affiliation(s)
- Ying Huang
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Kavya S Swarna
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
9
|
Elenjickal EJ, Travlos CK, Marques P, Mavrakanas TA. Anticoagulation in Patients with Chronic Kidney Disease. Am J Nephrol 2023; 55:146-164. [PMID: 38035566 PMCID: PMC10994631 DOI: 10.1159/000535546] [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: 10/09/2023] [Accepted: 11/27/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Both atrial fibrillation and venous thromboembolism (VTE) are highly prevalent among patients with chronic kidney disease (CKD). Until recently, warfarin was the most commonly prescribed oral anticoagulant. Direct oral anticoagulants (DOACs) have important advantages and have been shown to be noninferior to warfarin with respect to stroke prevention or recurrent VTE in the general population, with lower bleeding rates. This review article will provide available evidence on the use of DOACs in patients with CKD. SUMMARY In post hoc analyses of major randomized studies with DOACs for stroke prevention in atrial fibrillation, in the subgroup of participants with moderate CKD, defined as a creatinine clearance (CrCl) of 30-50 mL/min, dabigatran 150 mg and apixaban were associated with lower rates of stroke and systemic embolism, whereas apixaban and edoxaban were associated with lower bleeding and mortality rates, compared with warfarin. In retrospective observational studies in patients with advanced CKD (defined as a CrCl <30 mL/min) and atrial fibrillation, DOACs had similar efficacy with warfarin with numerically lower bleeding rates. All agents warrant dose adjustment in moderate-to-severe CKD. In patients on maintenance dialysis, the VALKYRIE trial, which was designed initially to study the effect of vitamin K on vascular calcification progression, established superiority for rivaroxaban compared with a vitamin K antagonist (VKA) in the extension phase. Two other clinical trials using apixaban (AXADIA and RENAL-AF) in this population were inconclusive due to recruitment challenges and low event rates. In post hoc analyses of randomized studies with DOACs in patients with VTE, in the subgroup of participants with moderate CKD at baseline, edoxaban was associated with lower rates of recurrent VTE, whereas rivaroxaban and dabigatran were associated with lower and higher bleeding rates, respectively, as compared to warfarin. KEY MESSAGES DOACs have revolutionized the management of atrial fibrillation and VTE, and they should be preferred over warfarin in patients with moderate-to-severe CKD with appropriate dose adjustment. Therapeutic drug monitoring with a valid technique may be considered to guide clinical management in individualized cases. Current evidence questions the need for oral anticoagulation in patients on maintenance dialysis with atrial fibrillation as both DOACs and VKAs are associated with high rates of major bleeding.
Collapse
Affiliation(s)
- Elias John Elenjickal
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Québec, Canada
| | - Christoforos K Travlos
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Québec, Canada
| | - Pedro Marques
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Québec, Canada
| | - Thomas A Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Québec, Canada
| |
Collapse
|
10
|
Morimoto T, Hoshino H, Matsuo Y, Ibuki T, Miyata K, Koretsune Y. Safety and Effectiveness of Apixaban Versus Warfarin in Japanese Patients with Nonvalvular Atrial Fibrillation Stratified by Renal Function: A Retrospective Cohort Study. Am J Cardiovasc Drugs 2023; 23:721-733. [PMID: 37847442 PMCID: PMC10625512 DOI: 10.1007/s40256-023-00611-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND We previously conducted a retrospective cohort study using chart review of oral anticoagulant-naïve Japanese patients with nonvalvular atrial fibrillation (NVAF) that assessed the risk of major bleeding and stroke/systemic embolism (SE) events of apixaban versus warfarin. METHODS In this subgroup analysis, we compared the risk of major bleeding and stroke/SE events by stratifying patients into four subgroups matched 1:1 using propensity score matching (PSM) according to baseline creatinine clearance (CrCl; mL/min): ≥ 15 to < 30, ≥ 30 to < 50, ≥ 50 to < 80, and ≥ 80. RESULTS Of the 7074 patients in the apixaban group and 4998 in the warfarin group eligible for inclusion in the analysis, 4385 were included in each group after PSM. Incidence rates of major bleeding and stroke/SE events were generally lower with apixaban versus warfarin across the CrCl subgroups. When all patients with a CrCl change of < 0 mL/min per year during the study period (apixaban, n = 3871; warfarin, n = 2635) were stratified into four subgroups based on the magnitude of CrCl decline (median CrCl change [mL/min] per year: - 1.09, - 3.48, - 7.54, and - 36.92 for apixaban, and - 1.10, - 3.65, - 7.85, and - 40.40 for warfarin), the incidence rates of major bleeding and stroke/SE events generally increased with an increasing CrCl decline per year in both groups. CONCLUSIONS In Japanese patients with NVAF, the safety and effectiveness of apixaban and warfarin were consistent across different renal subgroups, including those with severe renal impairment. Our results highlight the importance of monitoring renal function variations over time in patients with NVAF. CLINICALTRIALS GOV IDENTIFIER NCT03765242.
Collapse
Affiliation(s)
- Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawacho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Haruhiko Hoshino
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Yukako Matsuo
- Medical Department, Bristol Myers Squibb K.K., Tokyo, Japan
| | | | - Kayoko Miyata
- Medical Department, Bristol Myers Squibb K.K., Tokyo, Japan
| | - Yukihiro Koretsune
- Cardiovascular Division, National Hospital Organization Osaka National Hospital, Osaka, Japan
| |
Collapse
|
11
|
Ghantiwala KR, Dhamelia A, Vaghani DS, Panjiyar BK. Comparative Effectiveness of Different Anticoagulation Strategies in Atrial Fibrillation and Renal Dysfunction: A Systematic Review. Cureus 2023; 15:e48072. [PMID: 38046493 PMCID: PMC10689296 DOI: 10.7759/cureus.48072] [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] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of stroke and thromboembolism. Anticoagulation therapy can reduce this risk, but the optimal choice of anticoagulant in patients with AF and renal dysfunction is challenging. Renal dysfunction is a common comorbidity seen in patients with AF. Renal dysfunction would affect the pharmacokinetics and pharmacodynamics of anticoagulants and make the patient more prone to bleeding complications. This complicates the assessment of the risks, benefits, and ratio for starting anticoagulant drugs in patients with renal dysfunction. Therefore, there is always a therapeutic conundrum due to the increased risk of bleeding and thromboembolic events in AF patients with renal dysfunction. We conducted a systematic review to summarize the current literature and identify the challenges of anticoagulation strategies in AF with renal dysfunction. We examined 180 articles from reputable journals published from 2018 to June 2023 and selected eight papers for detailed analysis. The studies we chose included a variety of drug treatments, such as traditional therapies like vitamin K antagonists, factor Xa inhibitors, heparins, and direct thrombin inhibitors. This systematic review will provide comprehensive information on the latest data on the effectiveness of various pharmacological treatments (anticoagulation strategies) in AF patients with renal dysfunction. The aim is to help doctors and other healthcare decision-makers choose the best anticoagulation strategy in AF patients with renal dysfunction and to overcome their dilemma between bleeding risk and systemic thromboembolic events.
Collapse
Affiliation(s)
| | - Archi Dhamelia
- Internal Medicine, Mahatma Gandhi Mission (MGM) Medical College, Navi Mumbai, Navi Mumbai, IND
| | - Dhwani S Vaghani
- Internal Medicine, Mahatma Gandhi Mission (MGM) Medical College and Hospital, Aurangabad, Aurangabad, IND
| | - Binay K Panjiyar
- Global Clinical Scholars Research Training (GCSRT) and Postgraduate Medical Education (PGMEE), Harvard Medical School, Boston, USA
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| |
Collapse
|
12
|
Jun M, Scaria A, Andrade J, Badve SV, Birks P, Bota SE, Campain A, Djurdjev O, Garg AX, Ha J, Harel Z, Hemmelgarn B, Hockham C, James MT, Jardine MJ, Levin A, McArthur E, Ravani P, Shao S, Sood MM, Tan Z, Tangri N, Whitlock R, Gallagher M. Kidney function and the comparative effectiveness and safety of direct oral anticoagulants vs. warfarin in adults with atrial fibrillation: a multicenter observational study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:621-631. [PMID: 36302143 DOI: 10.1093/ehjqcco/qcac069] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 09/13/2023]
Abstract
AIMS The aim of this study was to determine the comparative effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in adults with atrial fibrillation (AF) by level of kidney function. METHODS AND RESULTS We pooled findings from five retrospective cohorts (2011-18) across Australia and Canada of adults with; a new dispensation for a DOAC or warfarin, an AF diagnosis, and a measure of baseline estimated glomerular filtration rate (eGFR). The outcomes of interest, within 1 year from the cohort entry date, were: (1) the composite of all-cause death, first hospitalization for ischaemic stroke, or transient ischaemic attack (effectiveness), and (2) first hospitalization for major bleeding defined as an intracranial, upper or lower gastrointestinal, or other bleeding (safety). Cox models were used to examine the association of a DOAC vs. warfarin with outcomes, after 1:1 matching via a propensity score. Kidney function was categorized as eGFR ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2. A total of 74 542 patients were included in the matched analysis. DOAC initiation was associated with greater or similar effectiveness compared with warfarin initiation across all eGFR categories [pooled HRs (95% CIs) for eGFR categories: 0.74(0.69-0.79), 0.76(0.54-1.07), 0.68(0.61-0.75) and 0.86(0.76-0.98)], respectively. DOAC initiation was associated with lower or similar risk of major bleeding than warfarin initiation [pooled HRs (95% CIs): 0.75(0.65-0.86), 0.81(0.65-1.01), 0.82(0.66-1.02), and 0.71(0.52-0.99), respectively). Associations between DOAC initiation, compared with warfarin initiation, and study outcomes were not modified by eGFR category. CONCLUSION DOAC use, compared with warfarin use, was associated with a lower or similar risk of all-cause death, ischaemic stroke, and transient ischaemic attack and also a lower or similar risk of major bleeding across all levels of kidney function.
Collapse
Affiliation(s)
- Min Jun
- The George Institute for Global Health, UNSW Sydney, Sydney, Newtown, NSW 2042, Australia
| | - Anish Scaria
- The George Institute for Global Health, UNSW Sydney, Sydney, Newtown, NSW 2042, Australia
| | - Jason Andrade
- University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| | - Sunil V Badve
- The George Institute for Global Health, UNSW Sydney, Sydney, Newtown, NSW 2042, Australia
| | - Peter Birks
- University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
| | | | - Anna Campain
- The George Institute for Global Health, UNSW Sydney, Sydney, Newtown, NSW 2042, Australia
| | | | - Amit X Garg
- ICES, ON, Canada
- Department of Medicine, Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Jeffrey Ha
- The George Institute for Global Health, UNSW Sydney, Sydney, Newtown, NSW 2042, Australia
| | - Ziv Harel
- Division of Nephrology, St. Michael's Hospital, Toronto, ON, Canada
| | - Brenda Hemmelgarn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Carinna Hockham
- The George Institute for Global Health, Imperial College London, London, UK
| | - Matthew T James
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Calgary AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Meg J Jardine
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Adeera Levin
- University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
- BC Renal, Vancouver, BC, Canada
| | | | - Pietro Ravani
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Calgary AB, Canada
| | | | - Manish M Sood
- The Ottawa Hospital Research Institute and Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Zhi Tan
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Calgary AB, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, MB, Canada
| | - Reid Whitlock
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, MB, Canada
| | - Martin Gallagher
- The George Institute for Global Health, UNSW Sydney, Sydney, Newtown, NSW 2042, Australia
- Liverpool Clinical School, UNSW Sydney, Sydney, NSWAustralia
| |
Collapse
|
13
|
Riaz IB, Fuentes H, Deng Y, Naqvi SAA, Yao X, Sangaralingham LR, Houghton DE, Padrnos LJ, Shamoun FE, Wysokinski WE, McBane RD. Comparative Effectiveness of Anticoagulants in Patients With Cancer-Associated Thrombosis. JAMA Netw Open 2023; 6:e2325283. [PMID: 37486628 PMCID: PMC10366701 DOI: 10.1001/jamanetworkopen.2023.25283] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2023] Open
Abstract
Importance Patterns of clinical utilization and comparative effectiveness of anticoagulants for cancer-associated thrombosis (CAT) remain largely unexplored. Objectives To assess patterns of and factors associated with anticoagulant use and to evaluate the comparative effectiveness of contemporary anticoagulants in patients with active cancer in a clinical setting. Design, Setting, and Participants This retrospective cohort study obtained deidentified OptumLabs electronic health record claims data from January 1, 2012, to September 30, 2019. Adult patients (≥18 years of age) with a primary cancer diagnosis (except skin cancer) during at least 1 inpatient or 2 outpatient visits within 6 months before the venous thromboembolism (VTE) date were included. Data were analyzed from April 2020 to September 2021. Exposures The patients were grouped according to the anticoagulant prescribed: (1) direct oral anticoagulants (DOACs), (2) low-molecular-weight heparin (LMWH), and (3) warfarin. Main Outcomes and Measures Odds ratios (ORs) were used to present the association between factors of interest and utilization of anticoagulants. Main efficacy outcomes included risk of VTE recurrence and all-cause mortality. Main safety outcomes included the risk of hospitalization due to major bleeding. Relative treatment effect estimates were expressed as hazard ratios (HRs) with 95% CIs. Results This study included 5100 patients (mean [SD] age, 66.3 [12.3] years; 2670 [52.4%] women; 799 [15.7%] Black, 389 [7.6%] Hispanic, and 3559 [69.8%] White individuals). Overall, 2512 (49.3%), 1488 (29.2%), and 1460 (28.6%) filled prescriptions for DOACs, LMWH, and warfarin, respectively. The median (IQR) treatment duration was 3.2 (1.0-6.5) months for DOACs, 3.1 (1.0-6.8) months for warfarin, and 1.8 (0.9-3.8) months for LWMH. Patients with lung (OR, 2.07; 95% CI, 1.12-3.65), urological (OR, 1.94; 95% CI,1.08-3.49), gynecological (OR, 4.25; 95% CI, 2.31-7.82), and colorectal (OR, 2.26; 95% CI, 1.20-4.32) cancer were associated with increased prescriptions for LMWH compared with DOACs. LMWH (HR, 1.47; 95% CI, 1.14-1.90) and warfarin (HR, 1.46; 95% CI, 1.13-1.87) were associated with an increased risk of VTE recurrences compared with DOACs. LMWH was associated with an increased risk of major bleeding (HR, 2.27; 95% CI, 1.62-3.20) and higher all-cause mortality (HR, 1.61; 95% CI, 1.15-2.25) compared with DOACs. Conclusions and Relevance In this comparative effectiveness study of claims-based data, patients with CAT received anticoagulation for a remarkably short duration in clinical settings. DOACs was associated with a lower risk of VTE recurrence, major bleeding, and mortality. Warfarin may still be considered for patients with contraindications to DOACs and those with poor persistence on LMWH.
Collapse
Affiliation(s)
- Irbaz Bin Riaz
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
| | - Harry Fuentes
- Department of Hematology and Oncology, Mayo Clinic, Rochester, Minnesota
| | - Yihong Deng
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Delivery Research, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Damon E Houghton
- Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Leslie J Padrnos
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
| | - Fadi E Shamoun
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, Arizona
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert D McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
14
|
Ha JT, Scaria A, Andrade J, Badve SV, Birks P, Bota SE, Campain A, Djurdjev O, Garg AX, Harel Z, Hemmelgarn B, Hockham C, James MT, Jardine MJ, Lam D, Levin A, McArthur E, Ravani P, Shao S, Sood MM, Tan Z, Tangri N, Whitlock R, Gallagher M, Jun M. Safety and Effectiveness of Rivaroxaban Versus Warfarin Across GFR Levels in Atrial Fibrillation: A Population-Based Study in Australia and Canada. Kidney Med 2023; 5:100675. [PMID: 37492112 PMCID: PMC10363562 DOI: 10.1016/j.xkme.2023.100675] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
Rationale & Objective The benefit-risk profile of rivaroxaban versus warfarin for atrial fibrillation (AF) in patients with chronic kidney disease is uncertain. We compared rivaroxaban with warfarin across the range of kidney function in adults with AF. Study Design Multicenter retrospective cohort. Setting & Participants Adults with AF and a measure of estimated glomerular filtration rate (eGFR); using administrative data from 5 jurisdictions across Australia and Canada (2011-2018). Kidney function was categorized as eGFR ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2. Patients receiving dialysis and kidney transplant recipients were excluded. Exposures New dispensation of either rivaroxaban or warfarin. Outcomes Composite (1) effectiveness outcome (all-cause death, ischemic stroke, or transient ischemic attack) and (2) major bleeding events (intracranial, gastrointestinal, or other) at 1 year. Analytical Approach Cox proportional hazards models accounting for propensity score matching were performed independently in each jurisdiction and then pooled using random-effects meta-analysis. Results 55,568 patients (27,784 rivaroxaban-warfarin user matched pairs; mean age 74 years, 46% female, 33.5% with eGFR <60 mL/min/1.73 m2) experienced a total of 4,733 (8.5%) effectiveness and 1,144 (2.0%) bleeding events. Compared to warfarin, rivaroxaban was associated with greater or similar effectiveness across a broad range of kidney function (pooled HRs of 0.72 [95% CI, 0.66-0.78], 0.78 [95% CI, 0.58-1.06], 0.70 [95% CI, 0.57-0.87], and 0.78 [95% CI, 0.62-0.99]) for eGFR ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2, respectively). Rivaroxaban was also associated with similar risk of major bleeding across all eGFR categories (pooled HRs of 0.75 [95% CI, 0.56-1.00], 1.01 [95% CI, 0.79-1.30], 0.87 [95% CI, 0.66-1.15], and 0.63 [95% CI, 0.37-1.09], respectively). Limitations Unmeasured treatment selection bias and residual confounding. Conclusions In adults with AF, rivaroxaban compared with warfarin was associated with lower or similar risk of all-cause death, ischemic stroke and transient ischemic attack and similar risk of bleeding across a broad range of kidney function. Plain-Language Summary This real-world study involved a large cohort of 55,568 adults with atrial fibrillation from 5 jurisdictions across Australia and Canada. It showed that the favorable safety (bleeding) and effectiveness (stroke or death) profile of rivaroxaban compared with warfarin was consistent across different levels of kidney function. This study adds important safety data on the use of rivaroxaban in patients with reduced kidney function, including those with estimated glomerular filtration rate <30 mL/min/1.73 m2 in whom the risks and benefits of rivaroxaban use is most uncertain. Overall, the study supports the use of rivaroxaban as a safe and effective alternative to warfarin for atrial fibrillation across differing levels of kidney function.
Collapse
Affiliation(s)
- Jeffrey T. Ha
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Anish Scaria
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Jason Andrade
- University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Sunil V. Badve
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Peter Birks
- University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Anna Campain
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | | | - Amit X. Garg
- ICES, Ontario, Canada
- Department of Medicine, Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ziv Harel
- Division of Nephrology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Brenda Hemmelgarn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Carinna Hockham
- The George Institute for Global Health, U.K., Imperial College London, London, United Kingdom
| | - Matthew T. James
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada
| | - Meg J. Jardine
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Dickson Lam
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| | - Adeera Levin
- University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- BC Provincial Renal Agency, Vancouver, British Columbia, Canada
| | | | - Pietro Ravani
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada
| | - Selena Shao
- BC Provincial Renal Agency, Vancouver, British Columbia, Canada
| | - Manish M. Sood
- The Ottawa Hospital Research Institute and Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Zhi Tan
- Cumming School of Medicine, Division of Nephrology, University of Calgary, Alberta, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Reid Whitlock
- Department of Internal Medicine, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
- Seven Oaks Hospital Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
| | - Martin Gallagher
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
- Liverpool Clinical School, UNSW Sydney, Sydney, NSW, Australia
| | - Min Jun
- The George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
| |
Collapse
|
15
|
Ngufor C, Yao X, Inselman JW, Ross JS, Dhruva SS, Graham DJ, Lee JY, Siontis KC, Desai NR, Polley E, Shah ND, Noseworthy PA. Identifying treatment heterogeneity in atrial fibrillation using a novel causal machine learning method. Am Heart J 2023; 260:124-140. [PMID: 36893934 PMCID: PMC10615250 DOI: 10.1016/j.ahj.2023.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/02/2023] [Accepted: 02/25/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Lifelong oral anticoagulation is recommended in patients with atrial fibrillation (AF) to prevent stroke. Over the last decade, multiple new oral anticoagulants (OACs) have expanded the number of treatment options for these patients. While population-level effectiveness of OACs has been compared, it is unclear if there is variability in benefit and risk across patient subgroups. METHODS We analyzed claims and medical data for 34,569 patients who initiated a nonvitamin K antagonist oral anticoagulant (non-vitamin K antagonist oral anticoagulant (NOAC); apixaban, dabigatran, and rivaroxaban) or warfarin for nonvalvular AF between 08/01/2010 and 11/29/2017 from the OptumLabs Data Warehouse. A machine learning (ML) method was applied to match different OAC groups on several baseline variables including, age, sex, race, renal function, and CHA2DS2 -VASC score. A causal ML method was then used to discover patient subgroups characterizing the head-to-head treatment effects of the OACs on a primary composite outcome of ischemic stroke, intracranial hemorrhage, and all-cause mortality. RESULTS The mean age, number of females and white race in the entire cohort of 34,569 patients were 71.2 (SD, 10.7) years, 14,916 (43.1%), and 25,051 (72.5%) respectively. During a mean follow-up of 8.3 (SD, 9.0) months, 2,110 (6.1%) of patients experienced the composite outcome, of whom 1,675 (4.8%) died. The causal ML method identified 5 subgroups with variables favoring apixaban over dabigatran; 2 subgroups favoring apixaban over rivaroxaban; 1 subgroup favoring dabigatran over rivaroxaban; and 1 subgroup favoring rivaroxaban over dabigatran in terms of risk reduction of the primary endpoint. No subgroup favored warfarin and most dabigatran vs warfarin users favored neither drug. The variables that most influenced favoring one subgroup over another included Age, history of ischemic stroke, thromboembolism, estimated glomerular filtration rate, Race, and myocardial infarction. CONCLUSIONS Among patients with AF treated with a NOAC or warfarin, a causal ML method identified patient subgroups with differences in outcomes associated with OAC use. The findings suggest that the effects of OACs are heterogeneous across subgroups of AF patients, which could help personalize the choice of OAC. Future prospective studies are needed to better understand the clinical impact of the subgroups with respect to OAC selection.
Collapse
Affiliation(s)
- Che Ngufor
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN.
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Jonathan W Inselman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Joseph S Ross
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Sanket S Dhruva
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA; Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - David J Graham
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Joo-Yeon Lee
- Office of Biostatistics, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | | | - Nihar R Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Eric Polley
- Department of Public Health Sciences, University of Chicago, Chicago, IL
| | | | - Peter A Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
16
|
Huqi A, Zoccali C, Giugliano RP, De Caterina R. Safety of non-vitamin K antagonist oral anticoagulants: concerns in patients with atrial fibrillation and glomerular hyperfiltration? Eur Heart J 2023; 44:322-325. [PMID: 35983667 DOI: 10.1093/eurheartj/ehac450] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/06/2022] [Accepted: 07/29/2022] [Indexed: 01/25/2023] Open
Affiliation(s)
- Alda Huqi
- Chair of Cardiology, University of Pisa and Cardiology Division, Pisa University Hospital, Via Paradisa 2, 56124 Pisa, Italy
| | - Carmine Zoccali
- Renal Research Institute, New York, NY, USA.,Associazione Ipertensione Nefrologia Trapianto Renale (IPNET), c/o Nefrologia-CNR, Ospedali Riuniti, Reggio Calabria, Italy
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Raffaele De Caterina
- Chair of Cardiology, University of Pisa and Cardiology Division, Pisa University Hospital, Via Paradisa 2, 56124 Pisa, Italy.,Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| |
Collapse
|
17
|
Montomoli M, Roca L, Rivera M, Fernandez-Prado R, Redondo B, Camacho R, Moyano C, Pampa S, Gonzalez A, Casas J, Kislikova M, Sanchez Horrillo A, Cabrera Cárdena A, Quiroga B, Rabasco C, Piqueras S, Suso A, Reque J, Villa J, Ojeda R, Arroyo D. Oral Anticoagulation in Patients with Chronic Kidney Disease and Non-Valvular Atrial Fibrillation: The FAERC Study. Healthcare (Basel) 2022; 10:healthcare10122566. [PMID: 36554089 PMCID: PMC9778700 DOI: 10.3390/healthcare10122566] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 11/30/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in patients with chronic kidney disease (CKD), and its presence is associated with a higher risk of stroke and mortality. MATERIAL AND METHODS The FAERC study performed a retrospective multicentre analysis of historical cohorts in which data were collected from arrhythmia diagnosis onwards. RESULTS We analysed a Spanish cohort of 4749 patients with CKD (mean eGFR 33.9 mL/min) followed up in the nephrology clinic, observing a 12.2% prevalence of non-valvular AF. In total, 98.6% of these patients were receiving anticoagulant treatment, mainly with coumarins (79.7%). Using direct-acting oral anticoagulants (DOACs) was associated with fewer cerebrovascular events than using acenocoumarol, but in contrast with other studies, we could not corroborate the association of risk of bleeding, coronary events, or death with a type of anticoagulant prescribed. CONCLUSIONS Atrial fibrillation is highly prevalent in renal patients. Direct-acting anticoagulants seem to be associated with fewer ischemic-embolic complications, with no differences in bleeding, coronary events, or mortality rates.
Collapse
Affiliation(s)
- Marco Montomoli
- Nephrology Department, Hospital Clínico Universitario de Valencia, Av. Blasco Ibañez 17, 46010 Valencia, Spain
- Correspondence:
| | - Lourdes Roca
- Nephrology Department, Hospital Universitario de La Plana, 12540 Villarreal, Spain
| | - Mariana Rivera
- Nephrology Department, Hospital Universitario Virgen de la Macarena, 41009 Sevilla, Spain
| | - Raul Fernandez-Prado
- Nephrology Department, Hospital Universitario Fundación Jiménez Díaz, 28040 Madrid, Spain
| | - Beatriz Redondo
- Nephrology Department, Hospital Universitario de Cruces, 48903 Bilbao, Spain
| | - Rosa Camacho
- Nephrology Department, Hospital Universitario Severo Ochoa, 28914 Leganes, Spain
| | - Cayetana Moyano
- Nephrology Department, Hospital Universitario Reina Sofía, 14004 Córdoba, Spain
| | - Saul Pampa
- Nephrology Department, Hospital Universitario Rey Juan Carlos, 28933 Móstoles, Spain
| | - Angela Gonzalez
- Nephrology Department, Hospital Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - Juan Casas
- Nephrology Department, Hospital Comarcal Francesc de Borja, 46702 Gandía, Spain
| | - Maria Kislikova
- Nephrology Department, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
| | - Ana Sanchez Horrillo
- Nephrology Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain
| | | | - Borja Quiroga
- Nephrology Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain
| | - Cristina Rabasco
- Nephrology Department, Hospital Universitario Reina Sofía, 14004 Córdoba, Spain
| | - Sara Piqueras
- Nephrology Department, Complejo Hospitalario Universitario de Albacete, 02006 Albacete, Spain
| | - Andrea Suso
- Nephrology Department, Hospital Universitario Severo Ochoa, 28914 Leganes, Spain
| | - Javier Reque
- Nephrology Department, Hospital General Universitario de Castellón, 12004 Castelló, Spain
| | - Juan Villa
- Nephrology Department, Hospital Universitario de Badajoz, 06080 Badajoz, Spain
| | - Raquel Ojeda
- Nephrology Department, Hospital Universitario Reina Sofía, 14004 Córdoba, Spain
| | - David Arroyo
- Nephrology Department, Hospital Universitario Gregorio Marañón, 28007 Madrid, Spain
| |
Collapse
|
18
|
Huqi A, Zoccali C, Giugliano RP, De Caterina R. The non-vitamin K antagonist oral anticoagulants in atrial fibrillation patients with high-normal renal function - A systematic review. Vascul Pharmacol 2022; 147:107123. [PMID: 36202288 DOI: 10.1016/j.vph.2022.107123] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/29/2022]
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) have revolutionized treatment of atrial fibrillation. Although benefits of anticoagulation therapy are clear, a minority of patients still experience treatment inefficacy or harm. All NOACs have varying degree of renal clearance, which may significantly affect plasma concentrations. Pivotal clinical trials have explored the effects of dose reduction in patients with chronic renal disease. None of these have, however, specifically addressed the need for a dose up-titration in patients with renal hyperfiltration, in whom lower drug plasma levels are to be expected. A signal for lower efficacy in this patient subset has recently emerged. We systematically assessed the peer-reviewed scientific literature on this topic, including a recently reported randomized pharmacokinetic study in renal hyperfiltrators also reporting on ischemic and bleeding events. We conclude that the reduction in NOAC plasma levels in AF patients with renal hyperfiltration is limited in extent and, does not translate into a clinically meaningful reduction in efficacy for NOACs as compared to vitamin K antagonists (VKAs) in such patients. At the current state of knowledge, NOAC current dosing should not be altered in patients with high-normal renal function.
Collapse
Affiliation(s)
- Alda Huqi
- Chair of Cardiology, University of Pisa and Cardiology Division, Pisa University Hospital, Pisa, Italy
| | - Carmine Zoccali
- Renal Research Institute, New York, USA; Associazione Ipertensione Nefrologia Trapianto Renale (IPNET) c/o Nefrologia-CNR, Ospedali Riuniti, Reggio Calabria, Italy
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Raffaele De Caterina
- Chair of Cardiology, University of Pisa and Cardiology Division, Pisa University Hospital, Pisa, Italy; Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy.
| |
Collapse
|
19
|
Matusik PT, Heleniak Z, Undas A, Undas A. Anticoagulant Treatment in Patients with Atrial Fibrillation and Chronic Kidney Disease: Practical Issues. Anatol J Cardiol 2022; 26:857-863. [PMID: 36444964 PMCID: PMC9797703 DOI: 10.5152/anatoljcardiol.2022.2426] [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] [Indexed: 11/29/2022] Open
Abstract
Up to 20% of patients with chronic kidney disease have atrial fibrillation, and 40%-50% of atrial fibrillation patients suffer from chronic kidney disease. The 2 diseases share several risk factors and frequently coincide with each other. Both entities are associ ated with a prothrombotic state, which contributes to increased thromboembolic risk. Atrial fibrillation patients with chronic kidney disease have elevated risk of stroke, major bleeding, and mortality. Clinical risk scores, including CHA2DS2-VASc score, HAS-BLED score, or ORBIT score have a limited value in adverse clinical outcome risk stratification in patients with severe chronic kidney disease. However, the inclusion of renal function in the R(2)-CHA2DS2-VASc score does not improve significantly thromboembolic risk predic tion in atrial fibrillation. There is growing evidence suggesting that biomarkers, including N-terminal pro-B-type natriuretic peptide, high-sensitivity cardiac troponin, cystatin C, or growth differentiation factor-15, might be helpful in the assessment of thromboembolic, bleeding, and/or mortality risk in atrial fibrillation patients with chronic kidney disease. The first-choice anticoagulant therapy is based on direct oral anticoagulants in this subgroup. The highest risk of adverse events is observed in end-stage renal disease, and in Europe, in contrast to the USA, solely warfarin is recommended in such atrial fibrillation patients. Treatment of atrial fibrillation patients with chronic kidney disease should be closely moni tored with the selection of right anticoagulant agents at the appropriate dose. The current review paper summarizes available evidence and the challenges of the management of atrial fibrillation patients with chronic kidney disease with practical implications.
Collapse
Affiliation(s)
- Paweł T. Matusik
- The John Paul II Hospital, Kraków, Poland,Department of Electrocardiology, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Zbigniew Heleniak
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Anetta Undas
- The John Paul II Hospital, Kraków, Poland,Department of Thromboembolic Diseases, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland,Corresponding author:Anetta Undas ✉
| | | | | | | | | | | |
Collapse
|
20
|
Lee WC, Liao TW, Fang HY, Wu PJ, Fang YN, Chen HC, Lin YS, Chang SH, Liu PY, Chen MC. Impact of baseline renal function on the efficacy and safety of different Anticoagulants in Atrial Fibrillation Patients - A cohort study. Thromb J 2022; 20:64. [PMID: 36229879 PMCID: PMC9559011 DOI: 10.1186/s12959-022-00423-w] [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: 07/13/2022] [Accepted: 10/04/2022] [Indexed: 11/28/2022] Open
Abstract
Background Vitamin K antagonists and different direct oral anticoagulants (DOACs) have different renal clearance rates. However, the impact of different stages of chronic renal impairment on the efficacy and safety of warfarin, dabigatran, rivaroxaban, apixaban, and edoxaban in atrial fibrillation (AF) patients remains unclear. Methods This study enrolled AF patients from the Chang Gung Research Database. The study endpoints included thromboembolic events, major/fatal bleeding, gastrointestinal (GI) bleeding and intracranial hemorrhage (ICH). The risks of time to study endpoints between groups were compared using a Cox proportional hazards regression model with adjustment. Results This study enrolled 3525 patients with moderate renal impairment (30 ≤ creatinine clearance (CrCl) < 60 mL/min), 2846 patients with mild renal impairment (60 ≤ CrCl < 90 mL/min) and 1153 patients with CrCl ≥ 90 mL/min. Over the 3.3 ± 0.9 years follow-up period, the cumulative thromboembolic events rates and the cumulative event rates of major/fatal bleeding and ICH did not differ among the warfarin and different DOAC groups at different stages of chronic renal impairment. The annual incidences of thromboembolic events, major/fatal bleeding, GI bleeding, and ICH were similar among the warfarin and different DOAC groups at different stages of renal impairment. Conclusion There did not appear to be major differences in bleeding or thromboembolic risk compared to warfarin in AF patients across a range of degree of renal failure when appropriate dose reductions of the DOACs are made. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00423-w.
Collapse
Affiliation(s)
- Wei-Chieh Lee
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, 83301, Kaohsiung City, Taiwan
| | - Ting-Wei Liao
- Center for Big Data Analytics and Statistics, Chang-Gung University and Hospital, Taipei, Taiwan
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, 83301, Kaohsiung City, Taiwan
| | - Po-Jui Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, 83301, Kaohsiung City, Taiwan
| | - Yen-Nan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, 83301, Kaohsiung City, Taiwan
| | - Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, 83301, Kaohsiung City, Taiwan
| | - Yu-Sheng Lin
- Division of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Shang-Hung Chang
- Center for Big Data Analytics and Statistics, Chang-Gung University and Hospital, Taipei, Taiwan
| | - Ping-Yen Liu
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Division of Cardiology, Internal Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao Sung District, 83301, Kaohsiung City, Taiwan.
| |
Collapse
|
21
|
On-treatment follow-up in real-world studies of direct oral anticoagulants in atrial fibrillation: Association with treatment effects. IJC HEART & VASCULATURE 2022; 40:101024. [PMID: 35663450 PMCID: PMC9157465 DOI: 10.1016/j.ijcha.2022.101024] [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: 12/19/2021] [Revised: 02/22/2022] [Accepted: 03/30/2022] [Indexed: 11/20/2022]
Abstract
Background Numerous observational studies support the safety and effectiveness of the direct oral anticoagulants (DOAC) for stroke prevention in atrial fibrillation (AF), but these data are often limited to short duration of follow-up. We aimed to assess the length of on-treatment follow-up in the accumulated real-world evidence and the relationship between follow-up duration and estimates of DOAC effectiveness and safety. Methods We searched the literature for observational studies reporting comparative effectiveness and safety outcomes of DOACs versus warfarin. In random-effects meta-analyses, we assessed associations of specific DOACs vs warfarin for stroke/systematic embolism (SE) and major bleeding. In meta-regression analyses, we assessed the correlation between the reported on-treatment follow-up with the effect sizes for stroke/SE and major bleeding outcomes. Results In 45 eligible observational studies, the average on-treatment follow-up was <1 year for all DOACs. In meta-analyses, all DOACs showed significantly lower risks of stroke/SE, but only dabigatran and apixaban showed lower risks for major bleeding compared to warfarin. There was no correlation between follow-up duration and magnitude of stroke/SE reduction for any of the DOACs. Longer follow-up correlated with greater major bleeding reduction for dabigatran (p = 0.006) and rivaroxaban (p = 0.033) as compared to warfarin, but it correlated with smaller major bleeding reduction for apixaban (p = 0.004). Conclusions The numerous studies of DOAC effectiveness and safety in the routine AF practice pertain to short treatment follow-up. Study follow-up correlates significantly with DOAC-specific vs warfarin associations for major bleeding.
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Nielsen PB, Søgaard M, Jensen M, Ording AG, Lip GY. Comparative effectiveness and safety of edoxaban versus warfarin in patients with atrial fibrillation: A nationwide cohort study. Int J Stroke 2021; 17:536-544. [PMID: 34142600 DOI: 10.1177/17474930211029441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE The effectiveness and safety of edoxaban 60 mg and 30 mg for stroke prevention compared with warfarin in patients with atrial fibrillation have not been well-described in a nationwide cohort of Caucasian patients treated in standard clinical practice. METHODS We used Danish nationwide registries to identify patients with atrial fibrillation during June 2016 and November 2018 who were treated with edoxaban or warfarin and computed rates per 100 person-years of thromboembolic, all-cause mortality, and bleeding events using an inverse probability of treatment weighting approach to account for baseline confounding. We used weighted pooled logistic regression to compute hazard ratios with 95% confidence intervals comparing events between edoxaban 60 mg and warfarin users; edoxaban 30 mg was not included in formal comparisons. RESULTS We identified 6451 atrial fibrillation patients, mean age was 72 years and 40% were females. A total of 1772 patients were treated with edoxaban 60 mg, 537 with edoxaban 30 mg, and 4142 with warfarin. The median CHA2DS2-VASc score was similar between warfarin and edoxaban 60 mg with a score of 3 (interquartile range (IQR) 2-4). In the inverse probability of treatment-weighted pseudo-population, the thromboembolic event rate for edoxaban 60 mg was 0.95 and 1.0 for warfarin, corresponding weighted hazard ratio of 1.00 (95% confidence intervals (CI) 0.59, 1.71). Edoxaban 60 mg users were associated with lower rates of all-cause mortality (3.93) compared to warfarin (6.04), with a hazard ratio of 0.64 (95% CI 0.47 to 0.88). The event rates for bleeding were 3.36 and 3.14, respectively; hazard ratio 1.09 (95% CI 0.77, 1.57). CONCLUSION Edoxaban 60 mg is a safe and effective treatment compared with warfarin for stroke prevention in routine clinical care for Danish (mainly Caucasian) patients with AF, with non-significantly different risks for stroke and clinically relevant bleeding, but lower all-cause mortality.
Collapse
Affiliation(s)
- Peter B Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Mette Søgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Martin Jensen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Anne G Ording
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gregory Yh Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| |
Collapse
|
24
|
Magnocavallo M, Bellasi A, Mariani MV, Fusaro M, Ravera M, Paoletti E, Di Iorio B, Barbera V, Della Rocca DG, Palumbo R, Severino P, Lavalle C, Di Lullo L. Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy. J Clin Med 2020; 10:jcm10010083. [PMID: 33379379 PMCID: PMC7796391 DOI: 10.3390/jcm10010083] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.
Collapse
Affiliation(s)
- Michele Magnocavallo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Antonio Bellasi
- Department of Research, Innovation and Brand Reputation, ASST-Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Maria Fusaro
- National Council of Research, Institute of Clinical Physiology, 56124 Pisa, Italy;
| | - Maura Ravera
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Ernesto Paoletti
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Biagio Di Iorio
- Department of Nephrology and Dialysis, Moscati Hospital, 83100 Avellino, Italy;
| | - Vincenzo Barbera
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
| | | | - Roberto Palumbo
- Department of Nephrology and Dialysis, Sant’Eugenio Hospital, 00144 Rome, Italy;
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
- Correspondence: ; Fax: +39-06-972233213
| |
Collapse
|