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Parks AL, Frankel DS, Kim DH, Ko D, Kramer DB, Lydston M, Fang MC, Shah SJ. Management of atrial fibrillation in older adults. BMJ 2024; 386:e076246. [PMID: 39288952 DOI: 10.1136/bmj-2023-076246] [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] [Indexed: 09/19/2024]
Abstract
Most people with atrial fibrillation are older adults, in whom atrial fibrillation co-occurs with other chronic conditions, polypharmacy, and geriatric syndromes such as frailty. Yet most randomized controlled trials and expert guidelines use an age agnostic approach. Given the heterogeneity of aging, these data may not be universally applicable across the spectrum of older adults. This review synthesizes the available evidence and applies rigorous principles of aging science. After contextualizing the burden of comorbidities and geriatric syndromes in people with atrial fibrillation, it applies an aging focused approach to the pillars of atrial fibrillation management, describing screening for atrial fibrillation, lifestyle interventions, symptoms and complications, rate and rhythm control, coexisting heart failure, anticoagulation therapy, and left atrial appendage occlusion devices. Throughout, a framework is suggested that prioritizes patients' goals and applies existing evidence to all older adults, whether atrial fibrillation is their sole condition, one among many, or a bystander at the end of life.
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Affiliation(s)
- Anna L Parks
- University of Utah, Division of Hematology and Hematologic Malignancies, Salt Lake City, UT, USA
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Dae H Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center; Boston Medical Center, Section of Cardiovascular Medicine, Boston, MA, USA
| | - Daniel B Kramer
- Richard A and Susan F Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Melis Lydston
- Massachusetts General Hospital, Treadwell Virtual Library, Boston, MA, USA
| | - Margaret C Fang
- University of California, San Francisco, Division of Hospital Medicine, San Francisco, CA, USA
| | - Sachin J Shah
- Massachusetts General Hospital, Division of General Internal Medicine, Center for Aging and Serious Illness, and Harvard Medical School, Boston, MA, USA
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Parks AL, Stevens SM, Woller SC. Anticoagulant therapy in renal insufficiency theme: Anticoagulation in complex situations. Thromb Res 2024; 241:109097. [PMID: 39094333 PMCID: PMC11418398 DOI: 10.1016/j.thromres.2024.109097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/12/2024] [Accepted: 07/15/2024] [Indexed: 08/04/2024]
Abstract
Many patients with impaired renal function have concurrent indications for anticoagulant therapy, including atrial fibrillation and venous thromboembolism. For mild chronic kidney disease, data from clinical trials and existing guidelines can be applied to clinical management. The benefits and harms of anticoagulation therapy in patients with more advanced renal impairment are nuanced, as both thrombotic and bleeding risk are increased. Until recently, data regarding anticoagulants in severe renal impairment were primarily observational, but emerging evidence includes a few small clinical trials and the emergence of novel agents hypothesized to have improved efficacy and safety in this population. In this review, we summarize existing data on anticoagulation in patients with chronic kidney disease. We suggest a framework for anticoagulation decision-making in the burgeoning worldwide population of patients with chronic kidney disease.
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Affiliation(s)
- Anna L Parks
- Division of Hematology & Hematologic Malignancies, Department of Internal Medicine, University of Utah, United States of America.
| | - Scott M Stevens
- Department of Medicine, Intermountain Medical Center, Intermountain Health, United States of America; Division of General Internal Medicine, Department of Internal Medicine, University of Utah, United States of America
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Intermountain Health, United States of America; Division of General Internal Medicine, Department of Internal Medicine, University of Utah, United States of America
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Sano M, Takegami M, Amano M, Tanaka H, Ando K, Kitai T, Miyake M, Komiya T, Izumo M, Kawai H, Eishi K, Yoshida K, Kimura T, Nawada R, Sakamoto T, Shibata Y, Fukui T, Minatoya K, Tsujita K, Sakata Y, Sugio K, Koyama T, Fujita T, Nishimura K, Izumi C, Furukawa Y. R 2-CHA 2DS 2-VASc Score for Cardiovascular Event Prediction After Bioprosthetic Valve Replacement - Subanalysis From the BPV-AF Registry. Circ Rep 2024; 6:341-348. [PMID: 39132334 PMCID: PMC11309778 DOI: 10.1253/circrep.cr-24-0033] [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: 04/02/2024] [Revised: 05/03/2024] [Accepted: 05/16/2024] [Indexed: 08/13/2024] Open
Abstract
Background There are few studies evaluating the prognostic prediction method in atrial fibrillation (AF) patients after bioprosthetic valve (BPV) replacement. The R2-CHA2DS2-VASc score is increasingly used for the prediction of cardiovascular (CV) events in patients with AF, device implantation, and acute coronary syndrome. We aimed to evaluate the predictive value of the R2-CHA2DS2-VASc score for future CV events in AF patients after BPV replacement. Methods and Results The BPV-AF, an observational, multicenter, prospective registry, enrolled AF patients who underwent BPV replacement. The primary outcome measure was a composite of stroke, systemic embolism, CV events including heart failure requiring hospitalization, and cardiac death. A total of 766 patients was included in the analysis. The mean R2-CHA2DS2-VASc score was 5.7±1.8. Low (scores 0-1), moderate (scores 2-4), and high (scores 5-11) R2-CHA2DS2-VASc score groups consisted of 12 (1.6%), 178 (23.2%), and 576 (75.2%) patients, respectively. The median follow-up period was 491 (interquartile range 393-561) days. Kaplan-Meier analysis showed a higher incidence of the composite CV events in the high R2-CHA2DS2-VASc score group (log rank test; P<0.001). Multivariate Cox proportional hazards regression analysis revealed that the R2-CHA2DS2-VASc score as a continuous variable was an independent predictor of composite CV outcomes (hazard ratio 1.36; 95% confidence interval 1.18-1.55; P<0.001). Conclusions The R2-CHA2DS2-VASc score is useful for CV risk stratification in AF patients after BPV replacement.
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Affiliation(s)
- Madoka Sano
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital Kobe Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center Osaka Japan
- Department of Public Health and Health Policy, Graduate School of Medicine, The University of Tokyo Tokyo Japan
| | - Masashi Amano
- Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center Osaka Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine Kobe Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital Kitakyushu Japan
| | - Takeshi Kitai
- Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center Osaka Japan
| | | | - Tatsuhiko Komiya
- Department of Public Cardiovascular Surgery, Kurashiki Central Hospital Okayama Japan
| | - Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine Kawasaki Japan
| | - Hiroya Kawai
- Department of Cardiology, Hyogo Prefectural Harima Himeji General Medical Center Hyogo Japan
| | - Kiyoyuki Eishi
- Department of Cardiovascular Surgery, Nagasaki University Hospital Nagasaki Japan
| | - Kiyoshi Yoshida
- Department of Cardiology, The Sakakibara Heart Institute of Okayama Okayama Japan
| | - Takeshi Kimura
- Division of Cardiology, Hirakata Kohsai Hospial Osaka Japan
| | - Ryuzo Nawada
- Department of Cardiology, Shizuoka City Shizuoka Hospital Shizuoka Japan
| | - Tomohiro Sakamoto
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center Kumamoto Japan
| | - Yoshisato Shibata
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center Miyazaki Japan
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University Kumamoto Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University Kyoto Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University Kumamoto Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Osaka Japan
| | - Kumiko Sugio
- Department of Primary Medical Science, Daiichi Sankyo Co., Ltd Tokyo Japan
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery, Kansai Medical University Osaka Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center Osaka Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center Osaka Japan
| | - Chisato Izumi
- Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center Osaka Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital Kobe Japan
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Jyrkilä H, Kaartinen K, Martola L, Halminen O, Haukka J, Linna M, Mustonen P, Putaala J, Teppo K, Kinnunen J, Hartikainen J, Airaksinen KEJ, Lehto M. Comorbidity and Medication Trends in Chronic Kidney Disease and Incident Atrial Fibrillation: A Nationwide Cohort Study. Nephron Clin Pract 2024:1-13. [PMID: 38861935 DOI: 10.1159/000539603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 05/25/2024] [Indexed: 06/13/2024] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) is associated with an increased incidence of atrial fibrillation (AF). Also, patients with AF are prone to adverse kidney outcomes. We examined comorbidities and medication use in patients with CKD and incident AF. METHODS The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) is a nationwide retrospective register-linkage study including data from 168,233 patients with incident AF from 2007 to 2018, with laboratory data from 2010 onwards. Estimated glomerular filtration rate (eGFR) was available for 124,936 patients. The cohort was divided into 5 CKD stages with separate groups for dialysis and kidney transplantation. RESULTS At AF diagnosis eGFR <60 mL/min/1.73 m2 was found in 27%, while 318 (0.3%) patients were on dialysis, and 188 (0.2%) had a functioning kidney transplant. Lowering eGFR yielded more comorbidities and medications. During 2010-2018 in patients with eGFR <60 mL/min/1.73 m2 prevalence of hypertension, dyslipidaemia, and diabetes increased from 82 to 88%, from 50 to 66% and from 25 to 33%, respectively (<0.001). Throughout the observation period, lipid-lowering medication was underused. CONCLUSION More than one-fourth of patients with incident AF also had CKD stage 3-5 (eGFR <60 mL/min/1.73 m2). Both comorbidities and medication use increased with worsening kidney function. Prevalence of major cardiovascular (CV) risk factors increased during 2010-2018, but the use of survival-affecting medications, such as lipid-lowering medication, was suboptimal at all stages of CKD. More attention should be given to the optimal treatment of risk factors in this high CV risk population.
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Affiliation(s)
- Heini Jyrkilä
- Helsinki University Hospital, Abdominal Center, Department of Nephrology and University of Helsinki, Helsinki, Finland
| | - Kati Kaartinen
- Helsinki University Hospital, Abdominal Center, Department of Nephrology and University of Helsinki, Helsinki, Finland
| | - Leena Martola
- Helsinki University Hospital, Abdominal Center, Department of Nephrology and University of Helsinki, Helsinki, Finland
| | - Olli Halminen
- Department of Industrial Engineering and Management, Aalto University, Espoo, Finland
| | - Jari Haukka
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Miika Linna
- University of Eastern Finland, Kuopio, Finland
| | - Pirjo Mustonen
- Department of Internal Medicine, Central Finland Health Care District, Jyväskylä, Finland
| | - Jukka Putaala
- Helsinki University Hospital, Department of Neurology and University of Helsinki, Helsinki, Finland
| | - Konsta Teppo
- Turku University Hospital, Department of Cardiology and University of Turku, Turku, Finland
| | - Janne Kinnunen
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juha Hartikainen
- Kuopio University Hospital, Heart Center, Department of Cardiology and University of Eastern Finland, Kuopio, Finland
| | - K E Juhani Airaksinen
- Turku University Hospital, Department of Cardiology and University of Turku, Turku, Finland
| | - Mika Lehto
- Jorvi Hospital, HUS Helsinki University Hospital, Espoo, Finland
- University of Helsinki, Helsinki, Finland
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Kreutz R, Kloss S, Enders D, Abdelgawwad K, Häckl D, Schmedt N, Bonnemeier H. Comparative effectiveness of factor Xa non-vitamin K antagonist oral anticoagulants versus phenprocoumon in patients with non-valvular atrial fibrillation. Int J Cardiol 2024; 404:131894. [PMID: 38437952 DOI: 10.1016/j.ijcard.2024.131894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/13/2024] [Accepted: 02/18/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Non-vitamin K antagonist oral anticoagulants (NOACs) have largely supplanted vitamin K antagonists (VKAs) for oral anticoagulation in non-valvular atrial fibrillation (NVAF). However, data on the real-world effectiveness of NOACs vs. phenprocoumon, a VKA widely used in Germany, are limited. The RELOADED study aimed to compare effectiveness of factor Xa NOACs and phenprocoumon in NVAF in clinical practice. METHODS Patients who started on a factor Xa NOAC or phenprocoumon for NVAF during the study period were enrolled from the Institute for Applied Healthcare Research Berlin. Patients were followed from first prescription until the end of exposure or available data. Primary outcomes were analyzed by Cox proportional hazard regression models and included ischemic stroke and systemic embolism for effectiveness, and intracranial hemorrhage (ICH) for safety. Subgroups of interest were patients with diabetes and patients with renal impairment. RESULTS The total study population was 64,920; 36.3% of patients initiated phenprocoumon, 34.4% initiated rivaroxaban, 25.0% apixaban, and 4.4% edoxaban. Treatment with phenprocoumon is associated with a similar risk of ischemic stroke/systemic embolism as treatment with rivaroxaban or apixaban; while rivaroxaban (adjusted hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.43-0.75) and apixaban (adjusted HR 0.43, 95% CI 0.31-0.6) were associated with a lower risk of ICH compared to phenprocoumon in NVAF patients. The use of rivaroxaban and apixaban was associated with a lower risk of developing kidney failure in patients with diabetes or renal impairment in comparison to those treated with phenprocoumon. CONCLUSION The factor Xa NOACs rivaroxaban and apixaban demonstrated similar effectiveness and lower rates of ICH compared with phenprocoumon in this study.
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Affiliation(s)
- Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Charitéplatz 1, 10117 Berlin, Germany.
| | | | - Dirk Enders
- InGef - Institute for Applied Health Research Berlin, Spittelmarkt 12, 10117 Berlin, Germany
| | | | - Dennis Häckl
- University Leipzig, Health Economics and Management, Grimmaische Straße 12, 04109 Leipzig, Germany; WIG2 - Scientific Institute for Health Economics and Health System Research, Markt 8, 04109 Leipzig, Germany
| | - Niklas Schmedt
- InGef - Institute for Applied Health Research Berlin, Spittelmarkt 12, 10117 Berlin, Germany
| | - Hendrik Bonnemeier
- University Medical Center Schleswig-Holstein, Department of Electrophysiology and Rhythmology, Arnold-Heller-Straße 3, 24105 Kiel, Germany
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Wang X, Sin CF, Teo KC, Leung WCY, Wong YK, Liu RKC, Fok JW, Ip BY, Kwan HH, Lee TC, Sheng B, Yip EKK, Yap DYH, Luo H, Lau KK. Impact of renal function variability on long-term prognosis in ischemic stroke patients with atrial fibrillation. Front Neurol 2024; 15:1294022. [PMID: 38711560 PMCID: PMC11071668 DOI: 10.3389/fneur.2024.1294022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 03/25/2024] [Indexed: 05/08/2024] Open
Abstract
Background Although renal dysfunction is associated with adverse clinical outcomes in patients with atrial fibrillation (AF) following stroke, the impact of renal function variability is unclear. Aim This study aimed to assess the association between renal function variability and various adverse clinical outcomes in patients with transient ischemic attack (TIA)/ischemic stroke and atrial fibrillation (AF). Methods We conducted a population-based study and retrospectively identified patients hospitalized with a diagnosis of TIA/ischemic stroke and AF during 2016-2020 using the Clinical Data Analysis and Reporting System of Hong Kong. Serial serum creatinine tested upon the onset of TIA/ischemic stroke and during their subsequent follow-up was collected. Renal function variability was calculated using the coefficient of variation of the estimated glomerular filtration rate (eGFR). Clinical endpoints that occurred during the study period were captured and included ischemic stroke/systemic embolism, intracerebral hemorrhage (ICH), total bleeding, major adverse cardiovascular events (MACE), cardiovascular, non-cardiovascular, and all-cause mortality. Competing risk regression and Cox proportional hazard regression models were used to assess the associations of renal function variability with the outcomes of interest. Results A total of 3,809 patients (mean age 80 ± 10 years, 43% men) who satisfied the inclusion and exclusion criteria were followed up for a mean of 2.5 ± 1.5 years (9,523 patient-years). The mean eGFR was 66 ± 22 mL/min/1.73 m2 at baseline, and the median number of renal function tests per patient during the follow-up period was 20 (interquartile range 11-35). After accounting for potential confounders, a greater eGFR variability was associated with increased risks of recurrent ischemic stroke/systemic embolism [fully adjusted subdistribution hazard ratio 1.11, 95% confidence interval (CI) 1.03-1.20], ICH (1.17, 1.01-1.36), total bleeding (1.13, 1.06-1.21), MACE (1.22, 1.15-1.30), cardiovascular (1.49, 1.32-1.69), non-cardiovascular (1.43, 1.35-1.52), and all-cause mortality (fully adjusted hazard ratio 1.44, 1.39-1.50). Conclusion Visit-to-visit renal function variability is independently associated with adverse clinical outcomes in TIA/ischemic stroke patients with AF. Further large-scale studies are needed to validate our results.
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Affiliation(s)
- Xiao Wang
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chun-fung Sin
- Department of Pathology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Kay-Cheong Teo
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - William C. Y. Leung
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yuen-Kwun Wong
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Roxanna K. C. Liu
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Joshua W. Fok
- Department of Medicine, Yan Chai Hospital, Hong Kong, Hong Kong SAR, China
| | - Bonaventure Y. Ip
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Hon Hang Kwan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, Hong Kong SAR, China
| | - Tsz Ching Lee
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Bun Sheng
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, Hong Kong SAR, China
| | - Edwin Kin-Keung Yip
- Department of Medicine and Geriatrics, Ruttonjee Hospital, Hong Kong, Hong Kong SAR, China
| | - Desmond Y. H. Yap
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Hao Luo
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Computer Science, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Kui-Kai Lau
- Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
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Pinto SS, Teixeira A, Henriques TS, Monteiro H, Martins C. AF-React study: Prevalence of thrombotic events in patients with atrial fibrillation receiving NOACs - real-world data analysis from northern Portugal primary healthcare. Front Med (Lausanne) 2024; 11:1273304. [PMID: 38681055 PMCID: PMC11046733 DOI: 10.3389/fmed.2024.1273304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 03/20/2024] [Indexed: 05/01/2024] Open
Abstract
Introduction Anticoagulation is recommended for stroke prevention in patients with atrial fibrillation (AF). The guidelines suggest non-vitamin K antagonist anticoagulants (NOACs) as the primary therapy for anticoagulation in AF. Several patient-related factors increase the risk of thrombotic events: elderly individuals, a previous history of stroke, and chronic kidney disease. This study aims to determine the association between NOACs and other patient variables in AF and the occurrence of thrombotic events. Methods The database included all adults with the code K78 (ICPC-2 code for AF) who received clinical care in Northern Portugal's Primary Health Care between January 2016 and December 2018 and were dispensed the same NOAC at the pharmacy. Results The results indicate that 10.2% of AF patients on NOAC anticoagulation experienced a stroke. Furthermore, patients treated with apixaban and dabigatran had higher odds of experiencing a stroke compared to those treated with rivaroxaban. Among patients with the same age, gender, and CHA2DS2Vasc Score, apixaban was significantly associated with a higher likelihood of thrombotic events than rivaroxaban. Discussion These results have not been previously reported in studies with real-world data; therefore, a more detailed analysis should be conducted to enhance the validity of these findings.
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Affiliation(s)
- Susana Silva Pinto
- São Tomé Family Health Unit (ACeS Santo Tirso/Trofa), Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
- CINTESIS@RISE - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Andreia Teixeira
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
- CINTESIS@RISE - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
- ADiT-LAB, Instituto Politécnico de Viana do Castelo, Rua Escola Industrial e Comercial Nun’Álvares, Viana do Castelo, Portugal
| | - Teresa S. Henriques
- CINTESIS@RISE - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
- CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Hugo Monteiro
- Regional Health Administration of Northern, Minister of Health, Porto, Portugal
| | - Carlos Martins
- CINTESIS@RISE - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
- #H4A Primary Health Care Research Network, Porto, Portugal
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8
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Ikeda S, Hiasa K, Inoue H, Yamashita T, Akao M, Atarashi H, Koretsune Y, Okumura K, Shimizu W, Suzuki S, Ikeda T, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Morishima Y, Takita A, Tsutsui H. Clinical outcomes and anticoagulation therapy in elderly non-valvular atrial fibrillation and heart failure patients. ESC Heart Fail 2024; 11:902-913. [PMID: 38213104 PMCID: PMC10966250 DOI: 10.1002/ehf2.14550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/28/2023] [Accepted: 09/20/2023] [Indexed: 01/13/2024] Open
Abstract
AIMS Atrial fibrillation (AF) and heart failure (HF) often coexist. Older age is strongly associated with stroke, HF, and mortality. The association between coexistence of HF and a risk of clinical outcomes and the effectiveness of anticoagulation therapy including direct oral anticoagulants (DOACs) in elderly patients with AF and HF have not been investigated. We aimed to evaluate 2 years of outcomes and to elucidate the efficacy of DOACs or warfarin in elderly AF patients in the All Nippon AF In the Elderly (ANAFIE) Registry with and without a history of HF. METHODS AND RESULTS The ANAFIE Registry is a multicentre, prospective observational study following elderly non-valvular AF patients aged ≥75 years for 2 years. Hazard ratios (HRs) were calculated based on the presence or absence of an HF diagnosis and DOAC or warfarin use at enrolment. Among 32 275 eligible patients, 12 116 (37.5%) had been diagnosed with HF. Patients with HF had significantly higher rates of HF hospitalization or cardiovascular death (HR 1.94, P < 0.001), cardiovascular events (HR 1.59, P < 0.001), cardiovascular death (HR 1.49, P < 0.001), all-cause death (HR 1.32, P < 0.001), and net clinical outcome including stroke/systemic embolism, major bleeding, and all-cause death (HR 1.23, P < 0.001), compared with those without HF; however, HRs for stroke/systemic embolism (HR 0.96, P = 0.56) and major bleeding (HR 1.14, P = 0.13) were similar. DOAC use was associated with a low risk of stroke/systemic embolism (HR 0.86, P = 0.19 in HF; HR 0.79, P = 0.016 in non-HF; P for interaction = 0.56), major bleeding (HR 0.71, P = 0.008 in HF; HR 0.75, P = 0.016 in non-HF; P for interaction = 0.74), HF hospitalization or cardiovascular death (HR 0.81, P < 0.001 in HF; HR 0.78, P < 0.001 in non-HF; P for interaction = 0.26), cardiovascular events (HR 0.83, P < 0.001 in HF; HR 0.82, P = 0.001 in non-HF; P for interaction = 0.65), cardiovascular death (HR 0.84, P = 0.12 in HF; HR 0.75, P = 0.035 in non-HF; P for interaction = 0.18), all-cause death (HR 0.89, P = 0.082 in HF; HR 0.80, P = 0.001 in non-HF; P for interaction = 0.091), and net clinical outcome (HR 0.88, P = 0.019 in HF; HR 0.81, P < 0.001 in non-HF; P for interaction = 0.21) compared with warfarin, irrespective of the presence or absence of HF. Analysis using the propensity score matching method showed similar associations. CONCLUSIONS Non-valvular AF patients aged ≥75 years with a history of HF had higher risks of cardiovascular events and mortality. DOACs were favourable to warfarin regardless of the coexistence of HF. These results might encourage the use of DOACs in elderly patients with non-valvular AF with or without HF.
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Affiliation(s)
- Shota Ikeda
- Department of Cardiovascular Medicine, Faculty of Medical SciencesKyushu University3‐1‐1 Maidashi, Higashi‐kuFukuoka812‐8582Japan
| | - Ken‐ichi Hiasa
- Department of Cardiovascular Medicine, Faculty of Medical SciencesKyushu University3‐1‐1 Maidashi, Higashi‐kuFukuoka812‐8582Japan
| | | | - Takeshi Yamashita
- Department of Cardiovascular MedicineThe Cardiovascular InstituteTokyoJapan
| | - Masaharu Akao
- Department of CardiologyNational Hospital Organization Kyoto Medical CenterKyotoJapan
| | | | - Yukihiro Koretsune
- Institute for Clinical ResearchNational Hospital Organization Osaka National HospitalOsakaJapan
| | - Ken Okumura
- Division of CardiologySaiseikai Kumamoto Hospital Cardiovascular CenterKumamotoJapan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of MedicineNippon Medical SchoolTokyoJapan
| | - Shinya Suzuki
- Department of Cardiovascular MedicineThe Cardiovascular InstituteTokyoJapan
| | - Takanori Ikeda
- Department of Cardiovascular MedicineToho University Faculty of MedicineTokyoJapan
| | - Kazunori Toyoda
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan
| | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and NeurologyCerebrovascular Center, National Hospital Organization Kyushu Medical CenterFukuokaJapan
| | - Takenori Yamaguchi
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
| | - Tetsuya Kimura
- Primary Medical Science DepartmentDaiichi Sankyo Co., Ltd.TokyoJapan
| | | | - Atsushi Takita
- Data Intelligence DepartmentDaiichi Sankyo Co., Ltd.TokyoJapan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical SciencesKyushu University3‐1‐1 Maidashi, Higashi‐kuFukuoka812‐8582Japan
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Piko N, Bevc S, Hojs R, Ekart R. Finerenone: From the Mechanism of Action to Clinical Use in Kidney Disease. Pharmaceuticals (Basel) 2024; 17:418. [PMID: 38675379 PMCID: PMC11054947 DOI: 10.3390/ph17040418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
Diabetic kidney disease is a frequent microvascular complication of diabetes and is currently the leading cause of chronic kidney disease and end-stage kidney disease worldwide. Although the prevalence of other complications of diabetes is falling, the number of diabetic patients with end-stage kidney disease in need of kidney replacement therapy is rising. In addition, these patients have extremely high cardiovascular risk. It is more than evident that there is a high unmet treatment need in patients with diabetic kidney disease. Finerenone is a novel nonsteroidal mineralocorticoid receptor antagonist used for treating diabetic kidney disease. It has predominant anti-fibrotic and anti-inflammatory effects and exhibits several renal and cardiac protective effects. This review article summarizes the current knowledge and future prospects of finerenone in treating patients with kidney disease.
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Affiliation(s)
- Nejc Piko
- Department of Dialysis, Clinic for Internal Medicine, University Medical Centre Maribor, 2000 Maribor, Slovenia;
| | - Sebastjan Bevc
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, 2000 Maribor, Slovenia; (S.B.); (R.H.)
- Medical Faculty, University of Maribor, 2000 Maribor, Slovenia
| | - Radovan Hojs
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, 2000 Maribor, Slovenia; (S.B.); (R.H.)
- Medical Faculty, University of Maribor, 2000 Maribor, Slovenia
| | - Robert Ekart
- Department of Dialysis, Clinic for Internal Medicine, University Medical Centre Maribor, 2000 Maribor, Slovenia;
- Medical Faculty, University of Maribor, 2000 Maribor, Slovenia
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10
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Fu EL, Desai RJ, Paik JM, Kim DH, Zhang Y, Mastrorilli JM, Cervone A, Lin KJ. Comparative Safety and Effectiveness of Warfarin or Rivaroxaban Versus Apixaban in Patients With Advanced CKD and Atrial Fibrillation: Nationwide US Cohort Study. Am J Kidney Dis 2024; 83:293-305.e1. [PMID: 37839687 DOI: 10.1053/j.ajkd.2023.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/16/2023] [Accepted: 08/26/2023] [Indexed: 10/17/2023]
Abstract
RATIONALE & OBJECTIVE Head-to-head data comparing the effectiveness and safety of oral anticoagulants in patients with atrial fibrillation (AF) and advanced chronic kidney disease (CKD) are lacking. We compared the safety and effectiveness of warfarin or rivaroxaban versus apixaban in patients with AF and non-dialysis-dependent CKD stage 4/5. STUDY DESIGN Propensity score-matched cohort study. SETTING & PARTICIPANTS 2 nationwide US claims databases, Medicare and Optum's deidentified Clinformatics Data Mart Database, were searched for the interval from January 1, 2013, through March 31, 2022, for patients with nonvalvular AF and CKD stage 4/5 who initiated warfarin versus apixaban (matched cohort, n=12,488) and rivaroxaban versus apixaban (matched cohort, n = 5,720). EXPOSURES Warfarin, rivaroxaban, or apixaban. OUTCOMES Primary outcomes included major bleeding and ischemic stroke. Secondary outcomes included all-cause mortality, major gastrointestinal bleeding, and intracranial bleeding. ANALYTICAL APPROACH Cox regression was used to estimate HRs, and 1:1 propensity-score matching was used to adjust for 80 potential confounders. RESULTS Compared with apixaban, warfarin initiation was associated with a higher rate of major bleeding (HR, 1.85; 95% CI, 1.59-2.15), including major gastrointestinal bleeding (1.86; 1.53-2.25) and intracranial bleeding (2.15; 1.42-3.25). Compared with apixaban, rivaroxaban was also associated with a higher rate of major bleeding (1.69; 1.33-2.15). All-cause mortality was similar for warfarin (1.08; 0.98-1.18) and rivaroxaban (0.94; 0.81-1.10) versus apixaban. Furthermore, no statistically significant differences for ischemic stroke were observed for warfarin (1.14; 0.83-1.57) or rivaroxaban (0.71; 0.40-1.24) versus apixaban, but the CIs were wide. Similar results were observed for warfarin versus apixaban in the positive control cohort of patients with CKD stage 3, consistent with randomized trial findings. LIMITATIONS Few ischemic stroke events, potential residual confounding. CONCLUSIONS In patients with AF and advanced CKD, rivaroxaban and warfarin were associated with higher rates of major bleeding compared with apixaban, suggesting a superior safety profile for apixaban in this high-risk population. PLAIN-LANGUAGE SUMMARY Different anticoagulants have been shown to reduce the risk of stroke in patients with atrial fibrillation, such as warfarin and direct oral anticoagulants like apixaban and rivaroxaban. Unfortunately, the large-scale randomized trials that compared direct anticoagulants versus warfarin excluded patients with advanced chronic kidney disease. Therefore, the comparative safety and effectiveness of warfarin, apixaban, and rivaroxaban are uncertain in this population. In this study, we used administrative claims data from the United States to answer this question. We found that warfarin and rivaroxaban were associated with increased risks of major bleeding compared with apixaban. There were few stroke events, with no major differences among the 3 drugs in the risk of stroke. In conclusion, this study suggests that apixaban has a better safety profile than warfarin and rivaroxaban.
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Affiliation(s)
- Edouard L Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School, Boston, Massachusetts; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yichi Zhang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Julianna M Mastrorilli
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
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11
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Ha JT, Freedman SB, Kelly DM, Neuen BL, Perkovic V, Jun M, Badve SV. Kidney Function, Albuminuria, and Risk of Incident Atrial Fibrillation: A Systematic Review and Meta-Analysis. Am J Kidney Dis 2024; 83:350-359.e1. [PMID: 37777059 DOI: 10.1053/j.ajkd.2023.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/19/2023] [Accepted: 07/31/2023] [Indexed: 10/02/2023]
Abstract
RATIONALE & OBJECTIVE Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist. However, it is not known whether CKD is an independent risk factor for incident AF. Therefore, we evaluated the association between markers of CKD-estimated glomerular filtration rate (eGFR) and albuminuria-and incident AF. STUDY DESIGN Systematic review and meta-analysis of cohort studies and randomized controlled trials. SETTING & STUDY POPULATIONS Participants with measurement of eGFR and/or albuminuria who were not receiving dialysis. SELECTION CRITERIA FOR STUDIES Cohort studies and randomized controlled trials were included that reported incident AF risk in adults according to eGFR and/or albuminuria. ANALYTICAL APPROACH Age- or multivariate-adjusted risk ratios (RRs) for incident AF were extracted from cohort studies, and RRs for each trial were derived from event data. RRs for incident AF were pooled using random-effects models. RESULTS 38 studies involving 28,470,249 participants with 530,041 incident AF cases were included. Adjusted risk of incident AF was greater among participants with lower eGFR than those with higher eGFR (eGFR<60 vs≥60mL/min/1.73m2: RR, 1.43; 95% CI, 1.30-1.57; and eGFR<90 vs≥90mL/min/1.73m2: RR, 1.42; 95% CI, 1.26-1.60). Adjusted incident AF risk was greater among participants with albuminuria (any albuminuria vs no albuminuria: RR, 1.43; 95% CI, 1.25-1.63; and moderately to severely increased albuminuria vs normal to mildly increased albuminuria: RR, 1.64; 95% CI, 1.31-2.06). Subgroup analyses showed an exposure-dependent association between CKD and incident AF, with the risk increasing progressively at lower eGFR and higher albuminuria categories. LIMITATIONS Lack of patient-level data, interaction between eGFR and albuminuria could not be evaluated, possible ascertainment bias due to variation in the methods of AF detection. CONCLUSIONS Lower eGFR and greater albuminuria were independently associated with increased risk of incident AF. CKD should be regarded as an independent risk factor for incident AF. PLAIN-LANGUAGE SUMMARY Irregular heartbeat, or atrial fibrillation (AF), is the commonest abnormal heart rhythm. AF occurs commonly in people with chronic kidney disease (CKD), and CKD is also common in people with AF. However, CKD in not widely recognized as a risk factor for new-onset or incident AF. In this research, we combined data on more than 28 million participants in 38 studies to determine whether CKD itself increases the chances of incident AF. We found that both commonly used markers of kidney disease (estimated glomerular filtration rate and albuminuria, ie, protein in the urine) were independently associated with a greater risk of incident AF. This finding suggests that CKD should be recognized as an independent risk factor for incident AF.
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Affiliation(s)
- Jeffrey T Ha
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Renal Medicine, St George Hospital, Sydney, NSW, Australia
| | - S Ben Freedman
- Heart Research Institute, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Dearbhla M Kelly
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Global Brain Health Institute, Trinity College Dublin, Ireland
| | - Brendon L Neuen
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Min Jun
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Sunil V Badve
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Renal Medicine, St George Hospital, Sydney, NSW, Australia.
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12
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Westreich R, Tsaban G, Barrett O, Kezerle L, Tsadok MA, Akriv A, Bachrach A, Leventer-Roberts M, Senderey AB, Haim M. Estimated glomerular filtration rate and the risk of stroke in individuals with diabetes mellitus and atrial fibrillation insight from a large contemporary population study. J Thromb Thrombolysis 2024; 57:322-329. [PMID: 37945939 DOI: 10.1007/s11239-023-02913-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) is associated with increased risk of embolic complications in non-valvular atrial fibrillation (NVAF). Impaired renal function (IRF) increases the risk of stroke as well, but this finding is not consistent among all studies. Our aim was to assess the incidence rates and risk of ischemic stroke and mortality by baseline Estimated Glomerular Filtration Rate (eGFR) levels Among individuals with AF and DM. METHODS A prospective, historical cohort study using the Clalit Health Services electronic medical records database. Among patients with AF and DM, we compared three groups according to eGFR levels: eGFR ≥ 60, between 30 and 60, and ≤ 30 (mL/min/1.73m2). RESULTS A total of 17,567 cases were included in the final analysis; of them, 11,013 (62.7%) had eGFR ≥ 60, 4930 (28%) had eGFR between 30 and 60, and 1624 (9.24%) with eGFR ≤ 30. The incidence of stroke per 100 person-years in the three study groups was: 1.88, 2.69, and 3.34, respectively (p < 0.001). IRF was associated with increased risk of stroke in univariate analysis, but not after multivariate adjustment (Adjusted Hazard Ratio (AHR) 0.96 {95%CI; 0.74-1.25} for eGFR 30-60 and 0.96 {95%CI; 0.60-1.55} for eGFR ≤ 30). Mortality per 100 person-years was 10.78, 21.49, and 41.55, respectively (p < 0.001). IRF was associated with increased mortality risk in univariate analysis, as well as in multivariate analysis (AHR 1.08 {95%CI; 0.98-1.18} for eGFR 30-60, and 1.59 {95%CI; 1.37-1.85} for eGFR ≤ 30. CONCLUSION In patients with NVAF and DM, IRF was not associated with an increased risk of stroke, but severe IRF (eGFR ≤ 30) was associated with increased mortality risk.
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Affiliation(s)
- Roi Westreich
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel.
| | - Gal Tsaban
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel
| | - Orit Barrett
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel
| | - Louise Kezerle
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel
| | - Meytal Avgil Tsadok
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Amichay Akriv
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Asaf Bachrach
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Maya Leventer-Roberts
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Adi Berliner Senderey
- Clalit Research Institute, Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel
| | - Moti Haim
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben- Gurion University of the Negev, PO Box 141, 84101, Beer-Sheva, Beer-Sheva, Israel
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13
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Liaw J, Liaw D, Dave C. Initiation patterns of anticoagulants for atrial fibrillation among older UK adults with and without chronic kidney disease, 2010-2020. Open Heart 2024; 11:e002515. [PMID: 38302138 PMCID: PMC10831461 DOI: 10.1136/openhrt-2023-002515] [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: 10/06/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND There is a paucity of data on the initiation patterns of anticoagulants among older atrial fibrillation patients with and without chronic kidney disease (CKD). SETTING AND METHODS We used the UK Clinical Practice Research Datalink (2010-2020) to conduct a retrospective cohort study to evaluate anticoagulant initiation patterns for older adults (≥65 years) with CKD (N=18 421) and without CKD (N=41 901), categorised by severity of CKD: stages 3a, 3b and 4, and initiation dose by respective direct oral anticoagulant (DOAC). RESULTS Over the study period, warfarin initiations sharply declined and were replaced by DOACs regardless of CKD status or stage. By 2020, patients with CKD were modestly more likely (8.8% difference) to initiate apixaban compared with those without CKD (58.8% vs 50.0%; p<0.01). Among patients with CKD, those with stages 3a and 3b CKD had higher apixaban initiations compared with stage 4 CKD (56.9% and 64.6% vs 52.9%, respectively; p<0.01). Conversely, patients with stage 4 CKD were over three times more likely to initiate warfarin (14.7%) compared with those with stage 3a (2.6%) and 3b (4.0%) CKD (p<0.01). Throughout the study period, there was a rise in the proportion of patients initiating the higher 10 mg daily dose for apixaban, with an increase of 20.6% (from 64.3% in 2013 to 84.9% in 2020; p value for trend <0.01) among patients without CKD, and 21.8% (53.1% to 74.9%; p<0.01), 24.4% (18.8% to 43.2%; p<0.01) and 18.5% (0.0% to 18.2%; p<0.01) among patients with stages 3a, 3b and 4 CKD, respectively. CONCLUSIONS AND RELEVANCE Initiation of DOACs increased regardless of CKD status and stage, although with a reduced magnitude in severe CKD. Apixaban emerged as the preferred agent, with a secular trend towards the higher initiation dose in all subgroups. These findings illuminate evolving trends and priorities in anticoagulant preferences among patients with and without CKD.
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Affiliation(s)
- Julia Liaw
- Centers for Pharmacoepidemiology and Treatment Sciences, Rutgers University, New Brunswick, New Jersey, USA
- Rutgers University, New Brunswick, New Jersey, USA
| | - Deborah Liaw
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Chintan Dave
- Rutgers University, New Brunswick, New Jersey, USA
- Department of Pharmacy Practice and Administration, Rutgers University, New Brunswick, New Jersey, USA
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14
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Basabe E, De La Flor JC, López de la Manzanara V, Nombela-Franco L, Narváez-Mejía C, Cruzado L, Villa D, Zamora R, Tapia M, Sastre MÁ, López Soberón E, Herrero Calvo JA, Suárez A, Martí Sánchez D. Percutaneous Left Atrial Appendage Closure in Patients with Non-Valvular Atrial Fibrillation and End-Stage Renal Disease on Hemodialysis: A Case Series. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:231. [PMID: 38399519 PMCID: PMC10890059 DOI: 10.3390/medicina60020231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024]
Abstract
Non-valvular atrial fibrillation (NVAF) is the most common cardiac arrhythmia in the general population, and its prevalence increases among patients with chronic kidney disease (CKD) undergoing hemodialysis. This population presents high risk of both hemorrhagic and thrombotic events, with little evidence regarding the use of oral anticoagulation treatment (OAT) and multiple complications arising from it; however, stroke prevention with percutaneous left atrial appendage closure (LAAC) is an alternative to be considered. We retrospectively describe the safety and efficacy of percutaneous LAAC in eight patients with NVAF and CKD on hemodialysis during a 12-month follow-up. The mean age was 78.8 years (range 64-86; SD ± 6.7), and seven patients were male. The mean CHA2DS2-VASC and HAS-BLED scores were high, 4.8 (SD ± 1.5) and 3.8 (SD ± 1.3), respectively. Seventy-five percent of the patients were referred for this intervention due to a history of major bleeding, with gastrointestinal bleeding being the most common type, while the remaining twenty-five percent of the patients were referred because of a high risk of bleeding. The percutaneous LAAC procedure was successfully completed in 100% of the patients, with complete exclusion of the appendage without complications or leaks exceeding 5 mm. There was one death not related to the procedure four days after the intervention. Among the other seven patients, no deaths, cardioembolic events or major bleeding were reported during the follow-up period. In our sample, percutaneous LAAC appears to be a safe and effective alternative to anticoagulation in patients with NVAF and CKD on hemodialysis.
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Affiliation(s)
- Elena Basabe
- Department of Cardiology, Hospital Central Defense Gómez Ulla, 28047 Madrid, Spain; (M.T.); (M.Á.S.); (E.L.S.); (A.S.); (D.M.S.)
| | - José C. De La Flor
- Department of Nephrology, Hospital Central Defense Gómez Ulla, 28047 Madrid, Spain;
| | | | | | - Carlos Narváez-Mejía
- Department of Nephrology, Hospital Universitario Puerta del Mar, 11009 Cádiz, Spain;
| | - Leónidas Cruzado
- Department of Nephrology, Hospital General Elche, 03203 Elche, Spain;
| | - Daniel Villa
- Department of Nephrology, Clínica Universidad de Navarra, 31008 Navarra, Spain;
| | - Rocío Zamora
- Department of Nephrology, Hospital Universitario General Villalba, 28400 Madrid, Spain;
| | - Manuel Tapia
- Department of Cardiology, Hospital Central Defense Gómez Ulla, 28047 Madrid, Spain; (M.T.); (M.Á.S.); (E.L.S.); (A.S.); (D.M.S.)
| | - Miguel Ángel Sastre
- Department of Cardiology, Hospital Central Defense Gómez Ulla, 28047 Madrid, Spain; (M.T.); (M.Á.S.); (E.L.S.); (A.S.); (D.M.S.)
| | - Edurne López Soberón
- Department of Cardiology, Hospital Central Defense Gómez Ulla, 28047 Madrid, Spain; (M.T.); (M.Á.S.); (E.L.S.); (A.S.); (D.M.S.)
| | - José A. Herrero Calvo
- Department of Nephrology, Hospital Clínico San Carlos, 28040 Madrid, Spain; (V.L.d.l.M.); (J.A.H.C.)
| | - Alfonso Suárez
- Department of Cardiology, Hospital Central Defense Gómez Ulla, 28047 Madrid, Spain; (M.T.); (M.Á.S.); (E.L.S.); (A.S.); (D.M.S.)
| | - David Martí Sánchez
- Department of Cardiology, Hospital Central Defense Gómez Ulla, 28047 Madrid, Spain; (M.T.); (M.Á.S.); (E.L.S.); (A.S.); (D.M.S.)
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15
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Yu M, Li X, Zong L, Wang Z, Lv Q. A Novel Body Mass Index-Based Thromboembolic Risk Score for Overweight Patients with Nonvalvular Atrial Fibrillation. Anatol J Cardiol 2024; 28:35-43. [PMID: 37961898 PMCID: PMC10796238 DOI: 10.14744/anatoljcardiol.2023.3373] [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: 04/26/2023] [Accepted: 09/15/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND A novel risk prediction model appears to be urgently required to improve the assessment of thrombotic risk in overweight patients with nonvalvular atrial fibrillation (NVAF). We developed a novel body mass index (BMI)-based thromboembolic risk score (namely AB2S score) for these patients. METHODS A total of 952 overweight patients with NVAF were retrospectively enrolled in this study with a 12-month follow-up. The primary endpoint was 1-year systemic thromboembolism and the time to thrombosis (TTT). The candidate risk variables identified by logistic regression analysis were included in the final nomogram model to construct AB2S score. The measures of model fit were evaluated using area under the curve (AUC), C-statistic, and calibration curve. The performance comparison of the AB2S score to the CHADS2 and CHA2DS2-VASc score was performed in terms of the AUC and decision analysis curve (DAC). RESULTS The AB2S score was constructed using 7 candidate risk variables, including a 3-category BMI (25 to 30, 30 to 34, or ≥35 kg/m2). It yielded a c-index of 0.885 (95% CI, 0.814-0.954) and an AUC of 0.885 (95% CI, 0.815-0.955) for predicting 1-year systemic thromboembolism in patients with NVAF. Compared to the CHADS2 score and CHA2DS2-VASc score, the AB2S score had greater AUC and DAC values in predicting the thromboembolic risk and better risk stratification in TTT (P <.0001, P =.082, respectively). CONCLUSION Our results highlighted the importance of a BMI-based AB2S score in determining systemic thromboembolism risk in overweight patients with NVAF, which may aid in decision-making for these patients to balance the effectiveness of anticoagulation from the underlying thrombotic risk.
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Affiliation(s)
- Meixiang Yu
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liuliu Zong
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zi Wang
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
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16
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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: 286] [Impact Index Per Article: 286.0] [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.
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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
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17
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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: 95] [Impact Index Per Article: 95.0] [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.
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18
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Tscharre M, Steiner D, Mutschlechner D, Ay C, Gremmel T. Anticoagulation in atrial fibrillation and end-stage kidney disease on hemodialysis: a meta-analysis of randomized trials comparing direct oral anticoagulants with vitamin K antagonists. Res Pract Thromb Haemost 2024; 8:102332. [PMID: 38404942 PMCID: PMC10885786 DOI: 10.1016/j.rpth.2024.102332] [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: 10/02/2023] [Revised: 01/04/2024] [Accepted: 01/07/2024] [Indexed: 02/27/2024] Open
Abstract
Background Only small randomized trials have investigated the efficacy and safety of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in patients with non-valvular atrial fibrillation (NVAF) and end-stage kidney disease. Objectives To perform a systematic review and meta-analysis comparing anticoagulation with DOACs to VKAs in patients with NVAF undergoing chronic hemodialysis. Methods A systematic search using Medline, Web of Science, and Embase was performed. All randomized trials comparing DOACs with VKAs in patients with NVAF undergoing chronic hemodialysis were included. As primary endpoint, we analyzed all-cause mortality. As secondary endpoints, we investigated total bleeding events, life-threatening or major bleeding events, and thromboembolic events or stroke. We used the odds ratio as outcome measure and fitted a random-effects model due to the expected heterogeneity. Results Three studies fulfilled the inclusion criteria comprising 383 patients (218 on apixaban or rivaroxaban, 165 on VKA). No significant difference between DOACs and VKAs regarding death (OR, 0.94; 95% CI, 0.55-1.63; p = .84), total bleedings (OR, 0.99; 95% CI, 0.63-1.54; p = .96) and life-threatening or major bleeding (OR, 0.65; 95% CI, 0.32-1.33, p = .24) was detected. There was a trend toward a reduction of thromboembolic events or stroke in patients receiving DOACs (OR, 0.39; 95% CI, 0.14-1.05; p = .06). Conclusion Orally administered activated factor X inhibitors carried a similar risk of bleeding and death when compared with VKAs in patients with NVAF undergoing chronic hemodialysis. Moreover, there was a trend towards a reduction of thromboembolic events or stroke in patients receiving DOACs.
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Affiliation(s)
- Maximilian Tscharre
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Austria
- Institute of Vascular Medicine and Cardiac Electrophysiology, Karl Landsteiner Society, St. Pölten, Austria
| | - Daniel Steiner
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - David Mutschlechner
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Thomas Gremmel
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
- Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, St. Pölten, Austria
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
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Ikeda S, An Y, Iguchi M, Ogawa H, Nakanishi Y, Minami K, Ishigami K, Aono Y, Doi K, Hamatani Y, Yoshizawa T, Ide Y, Fujino A, Ishii M, Masunaga N, Esato M, Tsuji H, Wada H, Hasegawa K, Abe M, Akao M. Proteinuria is independently associated with heart failure events in patients with atrial fibrillation: the Fushimi AF registry. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:758-767. [PMID: 36611235 DOI: 10.1093/ehjqcco/qcad001] [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: 10/28/2022] [Revised: 12/29/2022] [Accepted: 01/04/2023] [Indexed: 01/09/2023]
Abstract
AIMS Previous studies have shown that proteinuria is independently associated with the incidence of atrial fibrillation (AF), and is also associated with the incidence of cardiovascular events such as stroke and thromboembolism in patients with AF. However, the association of proteinuria with heart failure (HF) events in patients with AF remains unclear. METHODS AND RESULTS The Fushimi AF Registry is a community-based prospective study of patients with AF. Of the entire cohort of 4489 patients, 2164 patients had available data of proteinuria. We compared the clinical background and outcomes between patients with proteinuria (n = 606, 28.0%) and those without (n = 1558, 72.0%). Patients with proteinuria were older and had a higher prevalence of major co-morbidities. During the median follow-up of 5.0 years, the incidence rates of HF events (composite of cardiac death or HF hospitalization) were higher in patients with proteinuria than those without (4.1% vs. 2.1% person-year, P < 0.01). Multivariate analyses revealed that proteinuria was an independent risk factor of the incidence of HF events [adjusted hazard ratio (HR): 1.40, 95% confidence interval (CI): 1.13-1.74]. This association was consistent among the various subgroups, except for the age subgroup in which there was a significant interaction (P < 0.01) between younger (<75 years) (unadjusted HR: 3.03, 95% CI: 2.12-4.34) and older (≥75 years) patients (unadjusted HR: 1.59, 95% CI: 1.23-2.05). CONCLUSION Our community-based large prospective cohort suggests that proteinuria is independently associated with the incidence of HF events in Japanese patients with AF.
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Affiliation(s)
- Syuhei Ikeda
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Yoshimori An
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Moritake Iguchi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Yumiko Nakanishi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Kimihito Minami
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Kenjiro Ishigami
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Yuya Aono
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Kosuke Doi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Yasuhiro Hamatani
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Takashi Yoshizawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Yuya Ide
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Akiko Fujino
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Nobutoyo Masunaga
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Masahiro Esato
- Department of Cardiology, Heart Rhythm Section, Ogaki Tokushukai Hospital, Gifu, 503-0015, Japan
| | | | - Hiromichi Wada
- Division of Translational Research, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Koji Hasegawa
- Division of Translational Research, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan
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Hawkins NM, Wiebe N, Andrade JG, Sandhu RK, Ezekowitz JA, Kaul P, Tonelli M, McAlister FA. Kidney function monitoring and trajectories in patients with atrial fibrillation. Clin Exp Nephrol 2023; 27:981-989. [PMID: 37578638 DOI: 10.1007/s10157-023-02389-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/24/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) and chronic kidney disease (CKD) frequently co-exist. The frequency of kidney monitoring and range of kidney function in patients with AF in clinical practice are uncertain. METHODS All adult Albertans with AF between 2008 and 2017 were identified using ICD-9 and -10 codes 427.3 and I48. Kidney Disease Improving Global Outcomes (KDIGO) risk categories were defined using eGFR by the Chronic Kidney Disease Epidemiology Collaborative equation and albuminuria results within 6 months of eGFR measurement. eGFR trajectories were compared from baseline to maximum value within the following year. RESULTS Among 105,946 patients with AF, 16.0% were KDIGO category G1 (eGFR ≥ 90), 49.0% G2 (60-89.9), 19.8% G3a (45-59.9), 11.4% G3b (30-44.9), and G4 3.8% (15-29.9). Albuminuria was normal/mild 83.4%, moderate 11.7%, and severe 4.9%. Kidney monitoring was more common among people with lower eGFR and worse albuminuria, from approximately twice annually for G1-2/A1-2 to 8 times annually in stage G4A3. Approximately 60-80% of patients received guideline-recommended monitoring, consistent across KDIGO stages. With lower baseline eGFR, annual change in eGFR decreased while the relative proportion of patients who worsened compared to improved increased: for baseline eGFR 60-89.9, 16.7% worsened vs 6.7% improved, but for eGFR 30-44.9, 8.8% worsened but only 1.0% improved. CONCLUSION The frequency of kidney function monitoring in patients with AF increased with worsening KDIGO risk category and adhered to KDIGO guidelines in approximately three quarters of patients. A minority of patients had moderate to severe eGFR impairment, of whom most remained stable over 1 year.
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Affiliation(s)
- Nathaniel M Hawkins
- Centre for Cardiovascular Innovation, University of British Columbia, 2775 Laurel Street, 9th Floor, Room 9123, Vancouver, BC, V5Z 1M9, Canada.
| | - Natasha Wiebe
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jason G Andrade
- Centre for Cardiovascular Innovation, University of British Columbia, 2775 Laurel Street, 9th Floor, Room 9123, Vancouver, BC, V5Z 1M9, Canada
| | - Roopinder K Sandhu
- Smidt Heart Institute, Cedars-Sinai Medical Centre, Los Angeles, CA, USA
- Canadian Vigour Centre, University of Alberta, Edmonton, AB, Canada
| | - Justin A Ezekowitz
- Canadian Vigour Centre, University of Alberta, Edmonton, AB, Canada
- Division of Cardiology and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Padma Kaul
- Canadian Vigour Centre, University of Alberta, Edmonton, AB, Canada
- Division of Cardiology and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | | | - Finlay A McAlister
- Division of Cardiology and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
- Division of General Internal Medicine, University of Alberta, Edmonton, AB, Canada
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21
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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.
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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
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22
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Della Rocca DG, Magnocavallo M, Van Niekerk CJ, Gilhofer T, Ha G, D'Ambrosio G, Mohanty S, Gianni C, Galvin J, Vetta G, Lavalle C, Di Biase L, Sorgente A, Chierchia GB, de Asmundis C, Urbanek L, Schmidt B, Geller JC, Lakkireddy DR, Mansour M, Saw J, Horton RP, Gibson D, Natale A. Prognostic value of chronic kidney disease in patients undergoing left atrial appendage occlusion. Europace 2023; 25:euad315. [PMID: 37889200 PMCID: PMC10653166 DOI: 10.1093/europace/euad315] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/29/2023] [Indexed: 10/28/2023] Open
Abstract
AIMS Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist and share an increased risk of thrombo-embolism (TE). CKD concomitantly predisposes towards a pro-haemorrhagic state. Our aim was to evaluate the prognostic value of CKD in patients undergoing percutaneous left atrial appendage occlusion (LAAO). METHODS AND RESULTS A total of 2124 consecutive AF patients undergoing LAAO were categorized into CKD stage 1+2 (n = 1089), CKD stage 3 (n = 796), CKD stage 4 (n = 170), and CKD stage 5 (n = 69) based on the estimated glomerular filtration rate at baseline. The primary endpoint included cardiovascular (CV) mortality, TE, and major bleeding. The expected annual TE and major bleeding risks were estimated based on the CHA2DS2-VASc and HAS-BLED scores. A non-significant higher incidence of major peri-procedural adverse events (1.7 vs. 2.3 vs. 4.1 vs. 4.3) was observed with worsening CKD (P = 0.14). The mean follow-up period was 13 ± 7 months (2226 patient-years). In comparison to CKD stage 1+2 as a reference, the incidence of the primary endpoint was significantly higher in CKD stage 3 (log-rank P-value = 0.04), CKD stage 4 (log-rank P-value = 0.01), and CKD stage 5 (log-rank P-value = 0.001). Left atrial appendage occlusion led to a TE risk reduction (RR) of 72, 66, 62, and 41% in each group. The relative RR of major bleeding was 58, 44, 51, and 52%, respectively. CONCLUSION Patients with moderate-to-severe CKD had a higher incidence of the primary composite endpoint. The relative RR in the incidence of TE and major bleeding was consistent across CKD groups.
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Affiliation(s)
- Domenico G Della Rocca
- Texas Cardiac Arrhythmia Institute, St.David's Medical Center, 3000 North I-35, Suite 720, Austin, TX 78705, USA
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Av. du Laerbeek 101, 1090 Jette, Brussels, Belgium
| | - Michele Magnocavallo
- Texas Cardiac Arrhythmia Institute, St.David's Medical Center, 3000 North I-35, Suite 720, Austin, TX 78705, USA
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Rome, Italy
| | | | - Thomas Gilhofer
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Grace Ha
- Cardiac Arrhythmia Service and Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - Gabriele D'Ambrosio
- Arrhythmia Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St.David's Medical Center, 3000 North I-35, Suite 720, Austin, TX 78705, USA
| | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St.David's Medical Center, 3000 North I-35, Suite 720, Austin, TX 78705, USA
| | - Jennifer Galvin
- Cardiac Arrhythmia Service and Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - Giampaolo Vetta
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Av. du Laerbeek 101, 1090 Jette, Brussels, Belgium
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St.David's Medical Center, 3000 North I-35, Suite 720, Austin, TX 78705, USA
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Antonio Sorgente
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Av. du Laerbeek 101, 1090 Jette, Brussels, Belgium
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Av. du Laerbeek 101, 1090 Jette, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Av. du Laerbeek 101, 1090 Jette, Brussels, Belgium
| | - Lukas Urbanek
- Academy for Arrhythmias (FAFA), Abteilung für Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Boris Schmidt
- Academy for Arrhythmias (FAFA), Abteilung für Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - J Christoph Geller
- Arrhythmia Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany
- Otto-von-Guericke University School of Medicine, Pziger Str. 44, 39120 Magdeburg, Germany
| | | | - Moussa Mansour
- Cardiac Arrhythmia Service and Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Rodney P Horton
- Texas Cardiac Arrhythmia Institute, St.David's Medical Center, 3000 North I-35, Suite 720, Austin, TX 78705, USA
| | - Douglas Gibson
- Interventional Electrophysiology, Scripps Clinic, 9898 Genesee Ave, La Jolla, CA 92037, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St.David's Medical Center, 3000 North I-35, Suite 720, Austin, TX 78705, USA
- Interventional Electrophysiology, Scripps Clinic, 9898 Genesee Ave, La Jolla, CA 92037, USA
- Department of Cardiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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23
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Zheng S, Parikh RV, Tan TC, Pravoverov L, Patel JK, Horiuchi KM, Go AS. CKD stage-specific utility of two equations for predicting 1-year risk of ESKD. PLoS One 2023; 18:e0293293. [PMID: 37910454 PMCID: PMC10619781 DOI: 10.1371/journal.pone.0293293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND The Kidney Failure Risk Equation (KFRE) and Kaiser Permanente Northwest (KPNW) models have been proposed to predict progression to ESKD among adults with CKD within 2 and 5 years. We evaluated the utility of these equations to predict the 1-year risk of ESKD in a contemporary, ethnically diverse CKD population. METHODS We conducted a retrospective cohort study of adult members of Kaiser Permanente Northern California (KPNC) with CKD Stages 3-5 from January 2008-September 2015. We ascertained the onset of ESKD through September 2016, and calculated stage-specific estimates of model discrimination and calibration for the KFRE and KPNW equations. RESULTS We identified 108,091 eligible adults with CKD (98,757 CKD Stage 3; 8,384 CKD Stage 4; and 950 CKD Stage 5 not yet receiving kidney replacement therapy), with mean age of 75 years, 55% women, and 37% being non-white. The overall 1-year risk of ESKD was 0.8% (95%CI: 0.8-0.9%). The KFRE displayed only moderate discrimination for CKD 3 and 5 (c = 0.76) but excellent discrimination for CKD 4 (c = 0.86), with good calibration for CKD 3-4 patients but suboptimal calibration for CKD 5. Calibration by CKD stage was similar to KFRE for the KPNW equation but displayed worse calibration across CKD stages for 1-year ESKD prediction. CONCLUSIONS In a large, ethnically diverse, community-based CKD 3-5 population, both the KFRE and KPNW equation were suboptimal in accurately predicting the 1-year risk of ESKD within CKD stage 3 and 5, but more accurate for stage 4. Our findings suggest these equations can be used in1-year prediction for CKD 4 patients, but also highlight the need for more personalized, stage-specific equations that predicted various short- and long-term adverse outcomes to better inform overall decision-making.
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Affiliation(s)
- Sijie Zheng
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California, United States of America
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Rishi V. Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Thida C. Tan
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Leonid Pravoverov
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, California, United States of America
| | - Jignesh K. Patel
- Department of Nephrology, Kaiser Permanente Sacramento Medical Center, Sacramento, California, United States of America
| | - Kate M. Horiuchi
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, United States of America
- Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, California, United States of America
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
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Kourtidou C, Tziomalos K. Epidemiology and Risk Factors for Stroke in Chronic Kidney Disease: A Narrative Review. Biomedicines 2023; 11:2398. [PMID: 37760839 PMCID: PMC10525494 DOI: 10.3390/biomedicines11092398] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Patients with chronic kidney disease (CKD) have a higher risk ofboth ischemic and hemorrhagic stroke. This association appears to be partly independent from the higher prevalence of established risk factors for stroke in patients with CKD, including hypertension and atrial fibrillation. In the present review we aim to discuss the impact of CKD on the risk of stroke and stroke-related consequences, and explore the pathophysiology underpinning the increased risk of stroke in patients with CKD. We cover the clinical association between renal dysfunction and cerebrovascular disease including stroke, silent brain infarct, cerebral small vessel disease, microbleeds, and white matter hyperintensity, and discuss the underlying mechanisms.
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Affiliation(s)
- Christodoula Kourtidou
- Department of Nephrology, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece;
| | - Konstantinos Tziomalos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636 Thessaloniki, Greece
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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.
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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
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Simic J, Mihajlovic M, Zec N, Kovacevic V, Marinkovic M, Mujovic N, Potpara T. The impact of anticoagulation therapy on kidney function in patients with atrial fibrillation and chronic kidney disease. Expert Rev Cardiovasc Ther 2023; 21:937-945. [PMID: 37842943 DOI: 10.1080/14779072.2023.2270909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/11/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) and chronic kidney disease (CKD) are closely related. These diseases share common risk factors and are associated with increased risk of thromboembolic events. Choosing the appropriate oral anticoagulant therapy (OAC) in patients with AF and CKD is challenging. Deterioration of renal function is common in patients with AF treated with OACs, although not all OACs affect the kidneys equally. AREAS COVERED In this review, we aim to summarize the current knowledge of the prevention of thromboembolic events in patients with AF and CKD, focusing on the impact of specific OAC agents on renal function. EXPERT OPINION Consideration of OAC use is mandatory in patients with AF and CKD who are at increased risk of stroke or systemic embolism. Available evidence suggests that the use of non-vitamin K antagonist oral anticoagulants (NOACs) is associated with slower deterioration of renal function in comparison to Vitamin K antagonists (VKAs). Hence, a NOAC should be used in preference to VKAs in all NOAC-eligible patients with AF and CKD. Regarding patients with end-stage renal dysfunction and those on dialysis or renal replacement therapy, the use of NOAC should be considered in line with locally relevant formal recommendations.
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Affiliation(s)
- Jelena Simic
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Nevena Zec
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vladan Kovacevic
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Milan Marinkovic
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nebojsa Mujovic
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Tatjana Potpara
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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Endo D, Kinoshita T, Lee J, Machida Y, Nishida K, Sato Y, Yamamoto T, Tabata M. Left Atrial Appendage Closure During Coronary Bypass Surgery in Patients on Hemodialysis. Circ J 2023; 87:982-989. [PMID: 36928272 DOI: 10.1253/circj.cj-22-0573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Patients with end-stage renal disease on hemodialysis (ESRD-HD) have a lifelong risk of atrial fibrillation-related stroke. We compared clinical outcomes in ESRD-HD patients undergoing coronary artery bypass grafting (CABG) with and without concomitant left atrial appendage (LAA) closure. METHODS AND RESULTS Of 2,783 consecutive patients undergoing isolated CABG between 2002 and 2020, 242 patients had ESRD-HD with sinus rhythm. The primary outcome was a composite of death and stroke. An inverse probability (IP)-weighted cohort was created based on the propensity score. The 2 IP-weighted groups had well-balanced baseline and surgical backgrounds, with an equivalent follow-up. Five-year stroke-free survival was significantly higher in patients with LAA closure (log-rank test, P=0.035). The adjusted hazard ratio of LAA closure for death and stroke was 0.43 (95% confidence interval [CI] 0.20-0.92; P=0.023). Competing risk analysis showed that LAA closure was significantly associated with a risk reduction of stroke (subhazard ratio 0.26; 95% CI 0.08-0.96; P=0.028). No significant difference was observed in adjusted risk ratios for reoperation for bleeding, new atrial fibrillation, 30-day mortality, and readmission for heart failure. CONCLUSIONS Concomitant LAA closure during CABG can reduce the risk of death and stroke in ESRD-HD patients with normal sinus rhythm.
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Affiliation(s)
- Daisuke Endo
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
| | - Takeshi Kinoshita
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
| | - Jiyoung Lee
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
| | - Yoichiro Machida
- Department of Cardiovascular Surgery, Toda Chuo General Hospital
| | - Kosuke Nishida
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
| | - Yuichiro Sato
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
| | - Taira Yamamoto
- Department of Cardiovascular Surgery, Juntendo University School of Medicine Nerima Hospital
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
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Madken M, Mallick R, Rhodes E, Mahdavi R, Bader Eddeen A, Hundemer GL, Kelly DM, Karaboyas A, Robinson B, Bieber B, Molnar AO, Badve SV, Tanuseputro P, Knoll G, Sood MM. Development and Validation of a Predictive Risk Algorithm for Bleeding in Individuals on Long-term Hemodialysis: An International Prospective Cohort Study (BLEED-HD). Can J Kidney Health Dis 2023; 10:20543581231169610. [PMID: 37377481 PMCID: PMC10291537 DOI: 10.1177/20543581231169610] [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: 11/29/2022] [Accepted: 03/13/2023] [Indexed: 06/29/2023] Open
Abstract
Background Individuals with kidney disease are at a high risk of bleeding and as such tools that identify those at highest risk may aid mitigation strategies. Objective We set out to develop and validate a prediction equation (BLEED-HD) to identify patients on maintenance hemodialysis at high risk of bleeding. Design International prospective cohort study (development); retrospective cohort study (validation). Settings Development: 15 countries (Dialysis Outcomes and Practice Patterns Study [DOPPS] phase 2-6 from 2002 to 2018); Validation: Ontario, Canada. Patients Development: 53 147 patients; Validation: 19 318 patients. Measurements Hospitalization for a bleeding event. Methods Cox proportional hazards models. Results Among the DOPPS cohort (mean age, 63.7 years; female, 39.7%), a bleeding event occurred in 2773 patients (5.2%, event rate 32 per 1000 person-years), with a median follow-up of 1.6 (interquartile range [IQR], 0.9-2.1) years. BLEED-HD included 6 variables: age, sex, country, previous gastrointestinal bleeding, prosthetic heart valve, and vitamin K antagonist use. The observed 3-year probability of bleeding by deciles of risk ranged from 2.2% to 10.8%. Model discrimination was low to moderate (c-statistic = 0.65) with excellent calibration (Brier score range = 0.036-0.095). Discrimination and calibration of BLEED-HD were similar in an external validation of 19 318 patients from Ontario, Canada. Compared to existing bleeding scores, BLEED-HD demonstrated better discrimination and calibration (c-statistic: HEMORRHAGE = 0.59, HAS-BLED = 0.59, and ATRIA = 0.57, c-stat difference, net reclassification index [NRI], and integrated discrimination index [IDI] all P value <.0001). Limitations Dialysis procedure anticoagulation was not available; validation cohort was considerably older than the development cohort. Conclusion In patients on maintenance hemodialysis, BLEED-HD is a simple risk equation that may be more applicable than existing risk tools in predicting the risk of bleeding in this high-risk population.
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Affiliation(s)
- Mohit Madken
- Department of Medicine, The Ottawa Hospital, ON, Canada
| | | | - Emily Rhodes
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada
| | | | | | - Gregory L. Hundemer
- Department of Medicine, The Ottawa Hospital, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada
| | - Dearbhla M. Kelly
- Department of Nephrology, St. James Hospital, Dublin, Ireland
- Global Brain Health Institute, Trinity College Institute of Neuroscience, Trinity College Dublin, Ireland
| | | | - Bruce Robinson
- Department of Internal Medicine, University of Michigan, Ann Arbor, USA
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Amber O. Molnar
- ICES, Toronto, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sunil V. Badve
- Department of Renal Medicine, St. George Hospital, Sydney, NSW, Australia
- Renal and Metabolic Division, The George Institute for Global Health, Sydney, NSW, Australia
- UNSW Medicine and Health, Sydney, NSW, Australia
| | | | - Gregory Knoll
- Department of Medicine, The Ottawa Hospital, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada
- ICES, Toronto, ON, Canada
| | - Manish M. Sood
- Department of Medicine, The Ottawa Hospital, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, ON, Canada
- ICES, Toronto, ON, Canada
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29
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Cho MS, Choi HO, Hwang KW, Kim J, Nam GB, Choi KJ. Clinical benefits and risks of anticoagulation therapy according to the degree of chronic kidney disease in patients with atrial fibrillation. BMC Cardiovasc Disord 2023; 23:209. [PMID: 37098477 PMCID: PMC10131393 DOI: 10.1186/s12872-023-03236-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 04/11/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND The clinical benefits and risks of anticoagulation therapy in patients with chronic kidney disease (CKD) are still inconclusive. We describe the outcomes of patients with atrial fibrillation (AF) after anticoagulation therapy according to differences in creatinine clearance (CrCl). We also aimed to determine the patients who could benefit from anticoagulation therapy. METHODS This is a retrospective observational review of patients with AF who were managed at Asan Medical Center (Seoul, Korea) between January 1, 2006, and December 31, 2018. Patients were categorized into groups according to their baseline CrCl by Cockcroft-Gault equation and their outcomes were evaluated (CKD 1, ≥ 90 mL/min; CKD2, 60-89 mL/min; CKD3, 30-59 mL/min; CKD4, 15-29 mL/min; CKD 5, < 15 mL/min). The primary outcome was NACE (net adverse clinical events), defined as a composite of all-cause mortality, thromboembolic events, and major bleeding. RESULTS We identified 12,714 consecutive patients with AF (mean 64.6 ± 11.9 years, 65.3% male, mean CHA2DS2-VASc score 2.4 ± 1.6 points) between 2006 and 2017. In patients receiving anticoagulation therapy (n = 4447, 35.0%), warfarin (N = 3768, 84.7%) was used more frequently than NOACs (N = 673, 15.3%). There was a higher 3-year rate of NACE with renal function deterioration (14.8%, 18.6%, 30.3%, 44.0%, and 48.8% for CKD stages 1-5, respectively).The clinical benefit of anticoagulation therapy was most prominent in patients with CKD 1 (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.37-0.67), 2 (HR 0.64 CI 0.54-0.76), and 3 (HR 0.64 CI 0.54-0.76), but not in CKD 4 (HR 0.86, CI 0.57-1.28) and 5 (HR 0.81, CI 0.47-1.40). Among patients with CKD, the benefit of anticoagulation therapy was only evident in those with a high risk of embolism (CHA2DS2-VASc score ≥ 4, HR 0.25, CI 0.08-0.80). CONCLUSION Advanced CKD is associated with a higher risk of NACE. The clinical benefit of anticoagulation therapy was reduced with the increasing CKD stage.
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Affiliation(s)
- Min Soo Cho
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyung Oh Choi
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, 170, Jomaru-ro, Bucheon-si, Gyeonggi-do, 14584, Republic of Korea.
| | - Ki Won Hwang
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University of Medicine, Yangsan, Republic of Korea
| | - Jun Kim
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gi-Byoung Nam
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kee-Joon Choi
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Parada Barcia JA, Raposeiras Roubin S, Abu-Assi E, Erquicia PD, Lizancos Castro A, Lestón LR, Míguez JO, González Bermúdez I, Íñiguez-Romo A. Comparison of Stroke and Bleeding Risk Profile in Patients With Atrial Fibrillation and Chronic Kidney Disease. Am J Cardiol 2023; 196:31-37. [PMID: 37058875 DOI: 10.1016/j.amjcard.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 03/08/2023] [Accepted: 03/17/2023] [Indexed: 04/16/2023]
Abstract
Clinical decision making on anticoagulation in patients with chronic kidney disease with atrial fibrillation (AF) is challenging. The current strategies are based on small observational studies with conflicting results. This study explores the impact of glomerular filtration rate (GFR) in the embolic-hemorrhagic balance among a large cohort of patients with AF. The study cohort included 15,457 patients diagnosed with AF between January 2014 and April 2020. The risk of ischemic stroke and major bleeding was determined by competing risk regression. During a mean follow-up of 4.29 ± 1.82 years, 3,678 patients (23.80%) died, 850 (5.50%) had an ischemic stroke, and 961 (6.22%) had a major bleeding. The incidence of stroke and bleeding increased as baseline GFR decreased. Interestingly, in GFR <30 ml/min/1.73 m2, the bleeding risk was clearly higher than the embolic risk. As GFR decreased, anticoagulation was associated with an increased bleeding risk (subdistribution hazard ratio 1.700, 95% confidence interval [CI] 1.13 to 2.54, p = 0.009 for patients with GFR 30 to 59 ml/min/1.73 m2 and 2.00, 95% CI 0.77 to 5.21, p = 0.156 for subjects with <30 ml/min/1.73 m2 compared with those with GFR >60 ml/min/1.73 m2, respectively), but it was not associated with a decrease in embolic risk in patients with GFR <30 ml/min/1.73 m2 (subdistribution hazard ratio 1.91, 95% CI 0.73 to 5.04, p = 0.189) In GFR <30 ml/min/1.73 m2, the increase of major bleeding risk was higher than the increase of ischemic stroke risk, with a negative anticoagulation balance (greater increase in bleeding than reduction in embolism).
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Affiliation(s)
- José Antonio Parada Barcia
- Cardiology Department, University Hospital Alvaro Cunqueiro, Vigo, Spain; Medicine Department, University of Santiago de Compostela, Santiago, Spain
| | - Sergio Raposeiras Roubin
- Cardiology Department, University Hospital Alvaro Cunqueiro, Vigo, Spain; Cardiovascular Group, Health Research Institute Galicia Sur, Vigo, Spain; Cardiovascular Group, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain.
| | - Emad Abu-Assi
- Cardiology Department, University Hospital Alvaro Cunqueiro, Vigo, Spain; Cardiovascular Group, Health Research Institute Galicia Sur, Vigo, Spain
| | | | | | | | - Juan Ocampo Míguez
- Cardiology Department, University Hospital Alvaro Cunqueiro, Vigo, Spain
| | | | - Andrés Íñiguez-Romo
- Cardiology Department, University Hospital Alvaro Cunqueiro, Vigo, Spain; Cardiovascular Group, Health Research Institute Galicia Sur, Vigo, Spain
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31
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Quesado J, Dias L, Pereira-Macedo J, Duarte-Gamas L, Khairy A, Pinheiro M, Reis P, Andrade JP, Rocha-Neves J, Marreiros A. R2CHA2DS2-VA predicts the cardiovascular risk after carotid endarterectomy. Ann Vasc Surg 2023:S0890-5096(23)00116-4. [PMID: 36868457 DOI: 10.1016/j.avsg.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE R2CHA2DS2-VA score has been used to predict short and long-term outcomes in many cardiovascular diseases. This study aims to validate the R2CHA2DS2-VA score as a long-term major adverse cardiovascular events (MACE) predictor after CEA. Secondary outcomes were also assessed regarding the incidence of all-cause mortality, acute myocardial infarction (AMI), major adverse limb events (MALE), and acute heart failure (AHF). METHODS From January 2012 to December 2021, patients (n= 205) from a Portuguese tertiary care and referral center that underwent CEA with regional anesthesia (RA) for carotid stenosis were selected from a previously collected prospective database, and a post-hoc analysis was performed. Demographics and comorbidities were registered. Clinical adverse events were assessed 30-days after the procedure and in the subsequent long-term surveillance period. Statistical analysis was performed by the Kaplan-Meier method and Cox proportional hazards regression. RESULTS Of the patients enrolled, 78.5% were males with a mean age of 70.44 ± 8.9 years. Higher scores of R2CHA2DS2-VA were associated with long-term MACE (adjusted Hazard Ratio (aHR) 1.390; 95% Confidence Interval (CI) 1.173-1.647) and mortality (aHR 1.295; 95% CI 1.08-1.545) CONCLUSIONS: This study demonstrated the potential of the R2CHA2DS2-VA score to predict long-term outcomes such as AMI, AHF, MACE, and all-cause mortality in a population of patients submitted to carotid endarterectomy.
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Affiliation(s)
- João Quesado
- ICVS, Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal
| | - Lara Dias
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Juliana Pereira-Macedo
- Department of surgery - Centro Hospitalar do Médio Ave; Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Luís Duarte-Gamas
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - Ahmed Khairy
- Faculty of Medicine-Assiut University-Assiut-Egypt
| | - Marina Pinheiro
- ICVS, Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal; REQUIMTE, University of Porto, Porto, Portugal; Public Health Unit - ACES Cávado III , Braga, Portugal
| | - Pedro Reis
- Burn Unit-Department of Plastic Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - José P Andrade
- CINTESIS@RISE, Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto, Portugal; Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto, Portugal
| | - João Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto, Portugal.
| | - Ana Marreiros
- Faculdade de Medicina e Ciências Biomédicas da Universidade do Algarve, Portugal, ABC, Algarve Biomedical Center, Faro, Portugal
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Bansal N, Zelnick LR, An J, Harrison TN, Lee MS, Singer DE, Sung SH, Fan D, Go AS. Association of Kidney Function With Risk of Adverse Effects of Therapies for Atrial Fibrillation. Kidney Int Rep 2023; 8:606-618. [PMID: 36938096 PMCID: PMC10014389 DOI: 10.1016/j.ekir.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Atrial fibrillation (AF) is common in chronic kidney disease (CKD) and is treated with rate control medications, antiarrhythmic medications, as well as anticoagulation and procedures, each of which have associated risks. We aimed to evaluate the association of CKD status with the risks of adverse effects after initiation of AF therapies. Methods This was a cohort study of community-based adults who newly initiated rate control medications, antiarrhythmic medications, warfarin, direct oral anticoagulants (DOACs) or received AF procedures in the 1 year after diagnosis of AF. Baseline estimated glomerular filtration rate (eGFR) was calculated using outpatient serum creatinine measures. Adverse effects within 1 year related to each AF therapy or within 1 month of an AF procedure were ascertained from vital sign databases, electrocardiograms (ECGs), and administrative codes. Fine-Gray hazard models were used to study the association of eGFR categories with risk of adverse effects for each AF therapy. Results Among 115,564 patients with incident AF, lower eGFR (vs. eGFR ≥60 ml/min per 1.73 m2) was significantly associated with higher adjusted risk of adverse effects after initiation of rate control therapies (most commonly hypotension and bradycardia) as follows: eGFR 45-59 (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.07-1.22), 30-44 (HR 1.15, 95% CI 1.06-1.25), and 15-29 (HR 1.29, 95% CI: 1.12-1.47) ml/min per 1.73 m2. Lower eGFR was associated with higher adjusted risk of adverse effects (most commonly prolonged QRS and QTc intervals) after initiation of an antiarrhythmic medication (vs. eGFR >60 ml/min per 1.73 m2) as follows: eGFR 45-59 (HR 1.12, 95% CI 1.01-1.23) and eGFR<15 (HR 1.43, 95% CI 1.01-2.01) ml/min per 1.73 m2. Conclusion There was a graded association between lower eGFR and risk of major bleeding with warfarin use, with the greatest risk among those with eGFR <15 ml/min per 1.73 m2 (HR of 2.93, 95% CI 1.99-4.30). There was no association of eGFR with major bleeding in patients receiving DOACs. Rates of adverse effects within 1 month of an AF procedure were low among patients with (n = 18) and without (n = 41) CKD and was underpowered for further analyses. In conclusion, lower eGFR was associated with significantly higher risks of adverse effects after initiation of commonly used therapies to treat AF. These data may help inform the complex therapeutic decisions in patients with CKD and AF.
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Affiliation(s)
- Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
- Correspondence: Nisha Bansal, Division of Nephrology, University of Washington, 908 Jefferson St, 3rd floor, Seattle, Washington 98104, USA.
| | - Leila R. Zelnick
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Jaejin An
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Teresa N. Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Daniel E. Singer
- Clinical Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Medicine, Stanford University, Palo Alto, California, USA
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Bo D, Wang X, Wang Y. Survival benefits of oral anticoagulation therapy in acute kidney injury patients with atrial fibrillation: a retrospective study from the MIMIC-IV database. BMJ Open 2023; 13:e069333. [PMID: 36593000 PMCID: PMC9809246 DOI: 10.1136/bmjopen-2022-069333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/16/2022] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To find out the effect of different oral anticoagulation therapies (OAC) on mortality rate in patients with acute kidney injury (AKI) and atrial fibrillation (AF).DesignA retrospective study. SETTING This study was conducted in the Medical Information Mart for Intensive Care IV database. PARTICIPANTS A total of 19 672 patients diagnosed with AKI. MAIN OUTCOME MEASURES Patients were categorised into three groups: (1) AF; (2) AKI and AF, OAC-; (3) AKI and AF, OAC+. The primary endpoint was 30-day mortality. Secondary endpoints were the length of stay (LOS) in the intensive care unit (ICU) and hospital. Propensity score matching (PSM) and Cox proportional hazards model adjusted confounding factors. Linear regression was applied to assess the associations between OAC treatment and LOS. RESULTS After PSM, 2042 pairs of AKI and AF patients were matched between the patients who received OAC and those without anticoagulant treatment. Cox regression analysis showed that, OAC significantly reduce 30-day mortality compared with non-OAC (HR 0.30; 95% CI 0.25 to 0.35; p<0.001). Linear regression analysis revealed that OAC prolong LOS in hospital (11.3 days vs 10.0 days; p=0.013) and ICU (4.9 days vs 4.4 days; p<0.001). OAC did not improve survival in patients with haemorrhage (HR 0.67; 95% CI 0.34 to 1.29; p=0.23). Novel OAC did not reduce mortality in acute-on-chronic renal injury (HR 2.03; 95% CI 1.09 to 3.78; p=0.025) patients compared with warfarin. CONCLUSION OAC administration was associated with improved short-term survival in AKI patients concomitant with AF.
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Affiliation(s)
- Dan Bo
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xinchun Wang
- Department of Cardiology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yu Wang
- Department of Geriatrics, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Muacevic A, Adler JR, Kulkarni N. Anticoagulation for Stroke Prevention of Concomitant Atrial Fibrillation and End-Stage Renal Disease: Insights of Cardiologists and Nephrologists From India. Cureus 2022; 14:e32788. [PMID: 36694536 PMCID: PMC9857051 DOI: 10.7759/cureus.32788] [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: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Patients with concomitant atrial fibrillation (AF) and end-stage renal disease (ESRD) are at increased risk of thrombosis and bleeding. Diligent anticoagulant therapy that prevents major bleeding is essential for stroke prevention. There is a dearth of evidence and guidance on anticoagulation in this patient subset. Methods A validated questionnaire was sent to 500 physicians across India. Anonymized responses from 353 consenting physicians (275 cardiologists and 78 nephrologists) were analyzed. Results Most physicians opined that the risk of progression of chronic kidney disease (CKD) stages 2-4 to ESRD was 1-5%, and that >10% of patients with ESRD had concomitant AF. Most physicians perceived that the risk of ischemic stroke, major bleeding, and mortality was 30-40%, <15%, and >40% respectively in patients with concomitant AF and ESRD. The first critical goal for the management of these patients was 'reduction of thrombotic risk', followed by 'prevention of bleeding' and finally 'prevention of ESRD progression' (72.0%, 68.0%, and 67.1% participants, respectively). Most participating physicians (93.8%) preferred non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin for stroke prevention, and most of the participating physicians (94.9%) preferred an adjusted dose rather than the standard dose of the NOAC. Most of the responses were similar between cardiologists and nephrologists. Conclusion According to the survey response, patients with concomitant AF and ESRD have an increased risk of thrombosis, bleeding, and mortality. NOACs with dose adjustment are the preferred modality for stroke prevention among cardiologists and nephrologists in India, with the primary goal of preventing thrombotic events.
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Steiner D, Schmaldienst S, Lorenz M, Klauser-Braun R, Pabinger I, Ay C, Säemann M, Königsbrügge O. Atrial fibrillation and anticoagulation are associated with hospitalisations in patients with end-stage kidney disease on haemodialysis: a prospective population-based cohort study. Thromb J 2022; 20:71. [PMID: 36451221 PMCID: PMC9709737 DOI: 10.1186/s12959-022-00434-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Patients with end-stage kidney disease on haemodialysis suffer from frequent complications requiring hospitalisation. Atrial fibrillation is a burdensome comorbidity amongst patients on haemodialysis. We aimed to assess frequency, reasons, and duration of hospitalisations in haemodialysis patients and their association with atrial fibrillation and anticoagulation. METHODS Prevalent patients with end-stage kidney disease on haemodialysis were recruited into a prospective cohort study and observed for a median observation time of 3.4 years. Hospitalisations were recorded from discharge letters, medical records, and patient interviews. The association of atrial fibrillation, anticoagulation, and time-in-therapeutic range of vitamin K antagonist treatment with hospitalisations was analysed using negative binomial regression. RESULTS Out of 625 patients, 238 (38.1%) had atrial fibrillation. Median number of hospitalisations per patient was 3.0 (1.0-5.0). Incidence rate of hospitalisation was 1.7 per patient-year in all and 1.9 in atrial fibrillation patients, median duration per hospitalisation was 7.9 (4.8-12.9) and 8.8 (5.7-13.3) days, respectively. Most frequent reasons for hospitalisation were vascular access complication/intervention (11.7%) and infection/fever (11.4%), while bleeding events comprised 6.0% of all hospitalisations. Atrial fibrillation patients had 27% higher risk of hospitalisation than patients without atrial fibrillation (incidence rate ratio [IRR] 1.27, 95% confidence interval [CI] 1.10-1.47). In atrial fibrillation patients, anticoagulation (enoxaparin or phenprocoumon, 41.6% of AF patients) was associated with increased risk of all-cause (IRR 1.38, 95%CI 1.14-1.69) and bleeding-related hospitalisation (IRR 1.96, 95%CI 1.06-3.63). There was no association between anticoagulation and stroke-related hospitalisation. In atrial fibrillation patients on phenprocoumon, increasing time-in-therapeutic range was associated with decreased risk of all-cause (IRR 0.35, 95%CI 0.14-0.87), but not bleeding-related hospitalisation (IRR 0.13, 95%CI 0.01-1.38). CONCLUSION In haemodialysis patients, presence of atrial fibrillation and, among those with atrial fibrillation, anticoagulation were associated with higher risk of all-cause hospitalisation, including bleeding-related hospitalisation in the latter. Increasing time-in-therapeutic range in patients on vitamin K antagonist treatment was associated with decreased risk of all-cause, but not bleeding-related hospitalisation.
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Affiliation(s)
- Daniel Steiner
- grid.22937.3d0000 0000 9259 8492Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | | | | | | | - Ingrid Pabinger
- grid.22937.3d0000 0000 9259 8492Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Cihan Ay
- grid.22937.3d0000 0000 9259 8492Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Marcus Säemann
- Department of Medicine VI, Clinic Ottakring, Vienna, Austria
| | - Oliver Königsbrügge
- grid.22937.3d0000 0000 9259 8492Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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Abstract
PURPOSE OF REVIEW Atrial fibrillation is associated with a significant increase in stroke and systemic embolism. This review explores the areas of stroke prevention. RECENT FINDINGS In the last decade, NOAC has overtaken warfarin as the anticoagulant of choice for stroke prevention in AF. For patients unable to take anticoagulation, LAA closure has proven to be a valid option. The use of digital devices has led to widespread consumer-directed AF screening. It remains to be determined if all device detect AF pose the same amount of risk as recent studies have shown that short and infrequent episodes of AF may not benefit from anticoagulation. Stroke prevention is paramount in the management of AF. In this review we describe the risk factors contributing to stroke, recent advances in antithrombotic therapies, and the increasing role of digital health in guiding AF detection and stroke prevention.
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Affiliation(s)
- Xu Gao
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rod Passman
- Northwestern Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, 676 North St. Claire, Suite 600, Chicago, IL, 60657, USA.
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Wetmore JB, Weinhandl ED, Yan H, Reyes JL, Herzog CA, Roetker NS. Apixaban Dosing Patterns Versus Warfarin in Patients With Nonvalvular Atrial Fibrillation Receiving Dialysis: A Retrospective Cohort Study. Am J Kidney Dis 2022; 80:569-579.e1. [PMID: 35469965 DOI: 10.1053/j.ajkd.2022.03.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/01/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND & OBJECTIVES Comparison of clinical outcomes across anticoagulation regimens using different apixaban dosing or warfarin is not well-defined in patients with nonvalvular atrial fibrillation (AF) who are receiving dialysis. This study compared these outcomes in a US national cohort of patients with kidney failure receiving maintenance dialysis. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Patients receiving dialysis represented in the US Renal Data System database 2013-2018 who had AF and were treated with apixaban or warfarin. EXPOSURE First prescribed treatment with apixaban dosed according to the label, apixaban dosed below the label, or warfarin. OUTCOME Ischemic stroke/systemic embolism, major bleeding, and all-cause mortality. ANALYTICAL APPROACH Cox proportional hazards models with inverse probability of treatment weighting. Analyses simulating an intention-to-treat (ITT) approach as well as those incorporating censoring at drug switch or discontinuation (CAS) were also implemented. Inverse probability of censoring weighting was used to account for possible informative censoring. RESULTS Among 17,156 individuals, there was no difference in risk of stroke/systemic embolism among the label-concordant apixaban, below-label apixaban, and warfarin treatment groups. Both label-concordant (HR, 0.67 [95% CI, 0.55-0.81]) and below-label (HR, 0.68 [95% CI, 0.55-0.84]) apixaban dosing were associated with a lower risk of major bleeding compared with warfarin in ITT analyses. Compared with label-concordant apixaban, below-label apixaban was not associated with a lower bleeding risk (HR, 1.02 [95% CI, 0.78-1.34]). In the ITT analysis of mortality, label-concordant apixaban dosing was associated with a lower risk versus warfarin (HR, 0.85 [95% CI, 0.78-0.92]) while there was no significant difference in mortality between below-label dosing of apixaban and warfarin (HR, 0.97 [95% CI, 0.89-1.05]). Overall, results were similar for the CAS analyses. LIMITATIONS Study limited to US Medicare beneficiaries; reliance on administrative claims to ascertain outcomes of AF, stroke, and bleeding; likely residual confounding. CONCLUSIONS Among patients with nonvalvular AF undergoing dialysis, warfarin is associated with an increased risk of bleeding compared with apixaban. The risk of bleeding with below-label apixaban was not detectably less than with label-concordant dosing. Label-concordant apixaban dosing is associated with a mortality benefit compared to warfarin. Label-concordant dosing, rather than reduced-label dosing, may offer the most favorable benefit-risk trade-off for dialysis patients with nonvalvular AF.
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Affiliation(s)
- James B Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota; Division of Nephrology, University of Minnesota, Minneapolis, Minnesota.
| | - Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota; Hennepin County Medical Center and Department of Medicine, and Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Heng Yan
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jorge L Reyes
- Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Charles A Herzog
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota; Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
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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.
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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.
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Dilaveris PE, Antoniou CK, Caiani EG, Casado-Arroyo R, Climent AΜ, Cluitmans M, Cowie MR, Doehner W, Guerra F, Jensen MT, Kalarus Z, Locati ET, Platonov P, Simova I, Schnabel RB, Schuuring MJ, Tsivgoulis G, Lumens J. ESC Working Group on e-Cardiology Position Paper: accuracy and reliability of electrocardiogram monitoring in the detection of atrial fibrillation in cryptogenic stroke patients : In collaboration with the Council on Stroke, the European Heart Rhythm Association, and the Digital Health Committee. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022; 3:341-358. [PMID: 36712155 PMCID: PMC9707962 DOI: 10.1093/ehjdh/ztac026] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The role of subclinical atrial fibrillation as a cause of cryptogenic stroke is unambiguously established. Long-term electrocardiogram (ECG) monitoring remains the sole method for determining its presence following a negative initial workup. This position paper of the European Society of Cardiology Working Group on e-Cardiology first presents the definition, epidemiology, and clinical impact of cryptogenic ischaemic stroke, as well as its aetiopathogenic association with occult atrial fibrillation. Then, classification methods for ischaemic stroke will be discussed, along with their value in providing meaningful guidance for further diagnostic efforts, given disappointing findings of studies based on the embolic stroke of unknown significance construct. Patient selection criteria for long-term ECG monitoring, crucial for determining pre-test probability of subclinical atrial fibrillation, will also be discussed. Subsequently, the two major classes of long-term ECG monitoring tools (non-invasive and invasive) will be presented, with a discussion of each method's pitfalls and related algorithms to improve diagnostic yield and accuracy. Although novel mobile health (mHealth) devices, including smartphones and smartwatches, have dramatically increased atrial fibrillation detection post ischaemic stroke, the latest evidence appears to favour implantable cardiac monitors as the modality of choice; however, the answer to whether they should constitute the initial diagnostic choice for all cryptogenic stroke patients remains elusive. Finally, institutional and organizational issues, such as reimbursement, responsibility for patient management, data ownership, and handling will be briefly touched upon, despite the fact that guidance remains scarce and widespread clinical application and experience are the most likely sources for definite answers.
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Affiliation(s)
- Polychronis E Dilaveris
- First Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, 114 Vas. Sofias Avenue, 11527 Athens, Greece
| | - Christos Konstantinos Antoniou
- First Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, 114 Vas. Sofias Avenue, 11527 Athens, Greece
- Electrophysiology and Pacing Laboratory, Athens Heart Centre, Athens Medical Center, Marousi, Attica, Greece
| | - Enrico G Caiani
- Politecnico di Milano, Department of Electronics, Information and Biomedical Engineering, Milan, Italy
- National Council of Research, Institute of Electronics, Information and Telecommunication Engineering, Milan, Italy
| | - Ruben Casado-Arroyo
- Department of Cardiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Andreu Μ Climent
- ITACA Institute, Universitat Politècnica de València, Camino de Vera s/n, Valencia, Spain
| | - Matthijs Cluitmans
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martin R Cowie
- Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Wolfram Doehner
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charitéplatz 1, 10117 Berlin, Germany
- Department of Cardiology (Virchow Klinikum), and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, and German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital ‘Ospedali Riuniti Umberto I—Lancisi—Salesi’, Ancona, Italy
| | - Magnus T Jensen
- Department of Cardiology, Copenhagen University Hospital Amager & Hvidovre, Denmark
| | - Zbigniew Kalarus
- DMS in Zabrze, Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Emanuela Teresa Locati
- Arrhythmology & Electrophysiology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Pyotr Platonov
- Department of Cardiology, Clinical Sciences, Lund University Hospital, Lund, Sweden
| | - Iana Simova
- Cardiology Clinic, Heart and Brain Centre of Excellence—University Hospital, Medical University Pleven, Pleven, Bulgaria
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK) partner site, Hamburg/Kiel/Lübeck, Germany
| | - Mark J Schuuring
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Georgios Tsivgoulis
- Second Department of Neurology, ‘Attikon’ University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joost Lumens
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
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40
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Camm AJ, Sabbour H, Schnell O, Summaria F, Verma A. Managing thrombotic risk in patients with diabetes. Cardiovasc Diabetol 2022; 21:160. [PMID: 35996159 PMCID: PMC9396895 DOI: 10.1186/s12933-022-01581-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/25/2022] [Indexed: 12/24/2022] Open
Abstract
It is well known that diabetes is a prominent risk factor for cardiovascular (CV) events. The level of CV risk depends on the type and duration of diabetes, age and additional co-morbidities. Diabetes is an independent risk factor for atrial fibrillation (AF) and is frequently observed in patients with AF, which further increases their risk of stroke associated with this cardiac arrhythmia. Nearly one third of patients with diabetes globally have CV disease (CVD). Additionally, co-morbid AF and coronary artery disease are more frequently observed in patients with diabetes than the general population, further increasing the already high CV risk of these patients. To protect against thromboembolic events in patients with diabetes and AF or established CVD, guidelines recommend optimal CV risk factor control, including oral anticoagulation treatment. However, patients with diabetes exist in a prothrombotic and inflammatory state. Greater clinical benefit may therefore be seen with the use of stronger antithrombotic agents or innovative drug combinations in high-risk patients with diabetes, such as those who have concomitant AF or established CVD. In this review, we discuss CV risk management strategies in patients with diabetes and concomitant vascular disease, stroke prevention regimens in patients with diabetes and AF and how worsening renal function in these patients may complicate these approaches. Accumulating evidence from clinical trials and real-world evidence show a benefit to the administration of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with diabetes and AF.
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Affiliation(s)
- A John Camm
- Division of Cardiac and Vascular Sciences, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, Cranmer Terrace, SW17 0RE, UK.
| | - Hani Sabbour
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Warren Alpert School of Medicine, Brown University, Rhode Island, USA
| | - Oliver Schnell
- Forschergruppe Diabetes e.V., Neuherberg, Munich, Germany
| | | | - Atul Verma
- Southlake Regional Health Centre, Newmarket, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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41
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Munir MB, Hsu JC. Left atrial appendage occlusion should be offered only to select atrial fibrillation patients. Heart Rhythm O2 2022; 3:448-454. [PMID: 36097461 PMCID: PMC9463703 DOI: 10.1016/j.hroo.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Muhammad Bilal Munir
- Section of Electrophysiology, Division of Cardiology, University of California Davis, Sacramento, California
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California
| | - Jonathan C. Hsu
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California
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Zeng S, Zheng Y, Jiang J, Ma J, Zhu W, Cai X. Effectiveness and Safety of DOACs vs. Warfarin in Patients With Atrial Fibrillation and Frailty: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:907197. [PMID: 35811719 PMCID: PMC9263568 DOI: 10.3389/fcvm.2022.907197] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/31/2022] [Indexed: 11/20/2022] Open
Abstract
Background Patients with atrial fibrillation (AF) and frailty are a considerable group in clinical practice. However, existing studies provide insufficient evidence of anticoagulation strategies for these patients. Therefore, we conducted a meta-analysis to determine the effectiveness and safety outcomes of direct oral anticoagulants (DOACs) for these patients. Methods Randomized controlled trials or observational studies reporting the data about the DOACs and warfarin therapy among frail AF patients were included. The search was performed in the PubMed and Embase databases up to March 2022. Frailty was defined using the most widely used claims-based frailty index or the cumulative deficit model-based frailty index. Results A total of 4 studies involving 835,520 patients were included. Compared with warfarin, DOACs therapy reduced the risks of stroke or systemic embolism (HR = 0.79, 95%CI: 0.69–0.90), ischemic stroke (HR = 0.79, 95%CI: 0.71–0.87), hemorrhagic stroke (HR = 0.52, 95%CI: 0.35–0.76), and all-cause death (HR = 0.90, 95%CI: 0.84–0.96). In safety outcomes, DOACs was significantly associated with reduced risks of major bleeding (HR = 0.79, 95%CI: 0.64–0.97) and intracranial hemorrhage (HR = 0.58, 95%CI: 0.52–0.65) compared to warfarin, but there were no statistically differences in gastrointestinal bleeding (HR = 0.97, 95%CI: 0.73–1.29). Conclusions DOACs exerted superior effectiveness and safety outcome than warfarin in AF patients with frailty.
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Affiliation(s)
- Shan Zeng
- Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Department of Cardiology, First Affiliated Hospital, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Yuxiang Zheng
- Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Jingzhou Jiang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianyong Ma
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xingming Cai
- Department of Geriatric, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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43
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Welander F, Renlund H, Dimény E, Holmberg H, Själander A. Efficacy and safety of warfarin in patients with non-valvular atrial fibrillation and CKD G3-G5D. Clin Kidney J 2022; 15:1169-1178. [PMID: 35664263 PMCID: PMC9155221 DOI: 10.1093/ckj/sfac022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Indexed: 11/26/2022] Open
Abstract
Background Observational data comparing warfarin with no treatment for patients with non-valvular atrial fibrillation (NVAF) and severely reduced glomerular filtration rate (GFR) are conflicting and randomized controlled trials (RCTs) are lacking. Most studies do not provide information on warfarin treatment quality, making them difficult to compare. Methods This national cohort study investigates the risk of ischaemic stroke and major bleeding during warfarin treatment compared with no oral anticoagulants in patients with NVAF, GFR category 3-5 (G3-G5) or on dialysis (G5D), with kidney transplant recipients excluded, between 2009 and 2018. Data extracted from high-quality Swedish national healthcare registries, including the Swedish Renal Registry, AuriculA-the Swedish national quality registry for atrial fibrillation and anticoagulation-and the Stroke Registry. Results At enrolment of 12 106 patients, 21.4% were G3, 43.5% were G4, 11.6% were G5 and 23.6% were G5D. The mean time in the therapeutic range was 70%. Warfarin compared with no treatment showed a lower risk for ischaemic stroke for G3 {hazard ratio [HR] 0.37 [95% confidence interval (CI) 0.18-0.76]}, G4 [0.53 (0.38-0.74)] and G5 [0.49 (0.30-0.79)] and an increased risk of major bleeding in G4 [HR 1.22 (1.02-1.46)], G5 [1.52 (1.15-2.01)] and G5D [1.23 (1.00-1.51)]. All-cause mortality was more than halved on warfarin compared with no treatment in all GFR categories. Conclusions Warfarin treatment is associated with a lower risk of ischaemic stroke for patients with NVAF and G3, G4 and G5D at the cost of a higher risk of major bleeding for G4-G5D. Existing observational data are conflicting, stressing the need for RCTs on warfarin compared with no treatment in G4-G5D. Awaiting RCTs, it seems reasonable to treat selected patients on dialysis and NVAF with warfarin.
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Affiliation(s)
| | - Henrik Renlund
- Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Emöke Dimény
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Henrik Holmberg
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Anders Själander
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Ding WY, Potpara TS, Blomström-Lundqvist C, Boriani G, Marin F, Fauchier L, Lip GYH. Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry. Eur J Clin Invest 2022; 52:e13745. [PMID: 35000206 PMCID: PMC9287022 DOI: 10.1111/eci.13745] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. METHODS We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. RESULTS A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p < .001. Over 24 months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01-1.14] per 10 ml/min/1.73 m2 decrease), that was most notable in patients with eGFR <30 ml/min/1.73 m2 (HR 2.21 [95% CI, 1.23-3.99] compared to eGFR ≥90 ml/min/1.73 m2 ). CONCLUSION A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBERCV, Murcia, Spain
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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45
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Jamal S, Mughal MS, Kichloo A, Edigin E, Khan MZ, Minhas AMK, Ali M, Kanjwal K. Left atrial appendage closure using WATCHMAN device in chronic kidney disease and end stage renal disease patients. Pacing Clin Electrophysiol 2022; 45:866-873. [PMID: 35633309 DOI: 10.1111/pace.14537] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 04/20/2022] [Accepted: 05/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) and End Stage renal Disease are considered independent risk factors for developing atrial fibrillation (AF). Percutaneous occlusion of left atrial appendage (LAAC) using WATCHMAN device is a widely accepted alternative to anticoagulation therapy to prevent ischemic stroke in AF in patients who are not candidates for anticoagulation. There is limited data regarding the utilization and periprocedural safety of this intervention in patients with CKD/ESRD. METHODS We retrospectively reviewed all hospitalization from 2016 to 2017 with (ICD-10) procedure diagnosis code of LAA closure using WATCHMAN procedure with and without a secondary diagnosis of CKD/ESRD in acute-care hospitals across the United States using the national inpatient sample. Demographic variables (gender, race, income, hospital characteristics, medical comorbidities) were collected and compared. The primary outcomes were inpatient mortality, hospital length and cost of stay. RESULTS There were over 71 million discharges included in the combined 2016 and 2017 NIS database. 16,505 hospitalizations were for adult patients with a procedure code for LAA closure via watchman procedure. Of 16,505 patients 3,245 (19.66%) had CKD and ESRD. There was no statistically significant difference in mortality, length and cost of stay in patients with and without CKD/ESRD. There were no statistically significant differences in periprocedural cerebrovascular accidents in both groups. CONCLUSION Patients with and without ESRD/CKD who undergo LAA occlusion with Watchman have similar procedure related, in-hospital mortality and complications. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Shakeel Jamal
- Department of Internal Medicine, Central Michigan University, College of Medicine, Mount Pleasant, Michigan, USA
| | - Mohsin Sheraz Mughal
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, New Jersey, USA
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University, College of Medicine, Mount Pleasant, Michigan, USA
| | - Ehizogie Edigin
- Department of Internal Medicine, Cook County Health System, Chicago, Illinois, USA
| | - Muhammad Zia Khan
- Department of Internal Medicine, West Virginia University, Morgantown, West Virginia, USA
| | | | - Muzaffar Ali
- Department of Electrophysiology, Sheri Kashmir Institute of Medical Sciences, Srinagar, India
| | - Khalil Kanjwal
- Division of Cardiology, McLaren Greater Lansing, Lansing, Michigan, USA
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46
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Dalal J, Poncha F, Bansal S, Das A, Gupta P, Ghosh D, Rohatgi A, Hiremath MS, Bhargava K, Gopi A, Mali M. Expert Opinion on the Use of Novel Oral Anticoagulants for Stroke Prevention in Non-valvular Atrial Fibrillation for the Primary Care Setting in India: A Literature Review. Cureus 2022; 14:e25102. [PMID: 35733454 PMCID: PMC9205292 DOI: 10.7759/cureus.25102] [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] [Accepted: 05/14/2022] [Indexed: 11/29/2022] Open
Abstract
Atrial fibrillation (AF), the most prevalent cardiac arrhythmia encountered in clinical practice, is linked with substantial morbidity and mortality due to accompanying risk of stroke and thromboembolism. Patients with AF are at a five-fold higher risk of suffering from a stroke. Anticoagulation therapy, with either vitamin K antagonists or novel oral anticoagulants (NOACs), is a standard approach to reduce the risk. Consultant physicians (CPs) in India are the primary point of contact for the majority of patients before they approach a specialist. The CPs may face challenges in screening and diagnosing AF patients. The apprehensions associated with managing AF patients with anticoagulants, further add to the challenges of a CP. This review aimed to identify the key decision points for the CPs to diagnose AF and initiate anticoagulation in patients with non-valvular AF (NVAF) and bring to the table a simplified recommendation supported by expert opinion and guidelines for stroke prevention in NVAF patients.
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47
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Nishi H, Oishi N, Ogawa H, Natsue K, Doi K, Kawakami O, Aoki T, Fukuda S, Akao M, Tsukahara T. Predicting cerebral infarction in patients with atrial fibrillation using machine learning: The Fushimi AF registry. J Cereb Blood Flow Metab 2022; 42:746-756. [PMID: 34851764 PMCID: PMC9254038 DOI: 10.1177/0271678x211063802] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The CHADS2 and CHA2DS2-VASc scores are widely used to assess ischemic risk in the patients with atrial fibrillation (AF). However, the discrimination performance of these scores is limited. Using the data from a community-based prospective cohort study, we sought to construct a machine learning-based prediction model for cerebral infarction in patients with AF, and to compare its performance with the existing scores. All consecutive patients with AF treated at 81 study institutions from March 2011 to May 2017 were enrolled (n = 4396). The whole dataset was divided into a derivation cohort (n = 1005) and validation cohort (n = 752) after excluding the patients with valvular AF and anticoagulation therapy. Using the derivation cohort dataset, a machine learning model based on gradient boosting tree algorithm (ML) was built to predict cerebral infarction. In the validation cohort, the receiver operating characteristic area under the curve of the ML model was higher than those of the existing models according to the Hanley and McNeil method: ML, 0.72 (95%CI, 0.66-0.79); CHADS2, 0.61 (95%CI, 0.53-0.69); CHA2DS2-VASc, 0.62 (95%CI, 0.54-0.70). As a conclusion, machine learning algorithm have the potential to perform better than the CHADS2 and CHA2DS2-VASc scores for predicting cerebral infarction in patients with non-valvular AF.
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Affiliation(s)
- Hidehisa Nishi
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.,Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Naoya Oishi
- Medical Innovation Center, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kishida Natsue
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kento Doi
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Osamu Kawakami
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Tomokazu Aoki
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Shunichi Fukuda
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Tetsuya Tsukahara
- Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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Zhu H, Xu L, Liu X, Liu B, Zhai C, Wang R, Yang X. Anti-PLA2R antibody measured by ELISA predicts the risk of vein thrombosis in patients with primary membranous nephropathy. Ren Fail 2022; 44:594-600. [PMID: 35380081 PMCID: PMC8986254 DOI: 10.1080/0886022x.2022.2057861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Primary membranous nephropathy (PMN) is associated with the highest risk for developing venous thrombosis compared with other nephrotic diseases. The aim of the study was to assess the predictive value of the pathognomonic anti-phospholipase A2 receptor (PLA2R) antibody with regard to incidence of venous thrombosis in PMN. Methods A total of 365 in-hospital patients diagnosed with PMN were enrolled in the study. Anti-PLA2R antibody was detected by commercial enzyme-linked immunosorbent assay. Multivariate logistic regression was used to detect the independent risk factors for venous thrombosis. Results Thirty-seven patients (10.14%) had venous thrombosis. Patients with venous thrombosis had higher levels of cholesterol (CHOL), low-density lipoprotein (LDL), and D-dimer than those without venous thrombosis (p < .05). Patients with venous thrombosis had significantly lower levels of albumin (23.95 ± 5.53 vs. 26.18 ± 6.59 g/L, p = .049). No significant differences were found in proteinuria, serum creatinine, estimated glomerular filtration rate, platelets, and fibrinogen between patients with and without thrombosis. Anti-PLA2R antibody levels in patients with venous thrombosis were significantly higher than in patients without it (p = .002). In the univariate logistic regression, Ln anti-PLA2R antibody (OR: 1.340; p = .004), albumin (OR: 0.945; p = .050), CHOL (OR: 1.191; p = .006), and LDL (OR: 1.271, p = .006) were associated with venous thrombosis. Ln anti-PLA2R antibody (OR = 1.269; 95%CI: 1.032–1.561), and LDL (OR = 1.213; 95%CI: 1.017–1.448) were the independent risk factors for venous thrombosis (p < .05) in multivariate analysis. Conclusions Anti-PLA2R antibody was the independent risk factor for venous thrombosis in PMN. Larger prospective studies were warranted to verify the results in future.
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Affiliation(s)
- Huizi Zhu
- Department of Nephrology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Liang Xu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xiang Liu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Bing Liu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chunjuan Zhai
- Department of Cardiology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, China
| | - Rong Wang
- Department of Nephrology, Shandong Provincial Hospital, Shandong University, Jinan, China.,Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xiaowei Yang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Wang J, Zhang T, Yang YM, Zhu J, Zhang H, Shao XH. Relationship between creatinine clearance and clinical outcomes in Chinese emergency patients with atrial fibrillation. Ann Noninvasive Electrocardiol 2022; 27:e12942. [PMID: 35239203 PMCID: PMC9107078 DOI: 10.1111/anec.12942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 12/02/2022] Open
Abstract
Background Few real‐world data on the relation between creatinine clearance (CrCl) and adverse clinical outcomes in Chinese emergency department (ED) patients with nonvalvular atrial fibrillation (AF). Methods In this prospective, observational, multicenter AF study, enrolled AF patients presenting to an ED at 20 hospitals in China from November 2008 to October 2011, with a follow‐up of 12 month. A total of 863 AF patients with CrCl data were analyzed, and patients were categorized as CrCl ≥ 80, 50 ≤ CrCl < 80, 30 ≤ CrCl < 50, and CrCl < 30(ml/min). Outcomes of analyses were all‐cause death, cardiovascular death, thromboembolism (TE), and major bleeding. Results Among the whole patients, 126(14.6%) patients died during 12‐month follow‐up, 53(40.2%) among CrCl < 30 ml/min group, and 48(16.2%), 22(6.5%), and 3(3.2%) among 30 ≤ CrCl50, 50 ≤ Crl < 80, and CrCl ≥ 80 ml/min groups, respectively (p < 0.001). Cardiovascular death and TE rates also increased with decreasing CrCl. On multivariate analysis, patients with CrCl < 30 ml/min were associated with higher risks of all‐cause death (HR 5.567; 95%CI1.618–19.876; p = .007) and higher cardiovascular death (HR11.939; 95%CI1.439–99.031; p = .022) as compared with CrCl≥80 ml/min category. Nevertheless, for TE and major bleeding risk, CrCl groups showed no significant difference after adjustment for variables in CHA2DS2‐VASc score and status of warfarin prescription in our cohort. Conclusions In Chinese ED nonvalvular AF patients, incidence rates of death increased with reducing CrCl across the whole range of renal function. CrCl < 30 ml/min was associated with all‐cause death, cardiovascular death, but not for TE and major bleeding.
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Affiliation(s)
- Juan Wang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Zhang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan-Min Yang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhu
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Han Zhang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xing-Hui Shao
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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50
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Bansal N, Zelnick LR, Reynolds K, Harrison TN, Lee MS, Singer DE, Sung SH, Fan D, Go AS. Management of Adults with Newly Diagnosed Atrial Fibrillation with and without CKD. J Am Soc Nephrol 2022; 33:442-453. [PMID: 34921110 PMCID: PMC8819992 DOI: 10.1681/asn.2021060744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 12/06/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is highly prevalent in CKD and is associated with worse cardiovascular and kidney outcomes. Limited data exist on use of AF pharmacotherapies and AF-related procedures by CKD status. We examined a large "real-world" contemporary population with incident AF to study the association of CKD with management of AF. METHODS We identified patients with newly diagnosed AF between 2010 and 2017 from two large, integrated health care delivery systems. eGFR (≥60, 45-59, 30-44, 15-29, <15 ml/min per 1.73 m2) was calculated from a minimum of two ambulatory serum creatinine measures separated by ≥90 days. AF medications and procedures were identified from electronic health records. We performed multivariable Fine-Gray subdistribution hazards regression to test the association of CKD severity with receipt of targeted AF therapies. RESULTS Among 115,564 patients with incident AF, 34% had baseline CKD. In multivariable models, compared with those with eGFR >60 ml/min per 1.73 m2, patients with eGFR 30-44 (adjusted hazard ratio [aHR] 0.91; 95% CI, 0.99 to 0.93), 15-29 (aHR, 0.78; 95% CI, 0.75 to 0.82), and <15 ml/min per 1.73 m2 (aHR, 0.64; 95% CI, 0.58-0.70) had lower use of any AF therapy. Patients with eGFR 15-29 ml/min per 1.73 m2 had lower adjusted use of rate control agents (aHR, 0.61; 95% CI, 0.56 to 0.67), warfarin (aHR, 0.89; 95% CI, 0.84 to 0.94), and DOACs (aHR, 0.23; 95% CI, 0.19 to 0.27) compared with patients with eGFR >60 ml/min per 1.73 m2. These associations were even stronger for eGFR <15 ml/min per 1.73 m2. There was also a graded association between CKD severity and receipt of AF-related procedures (vs eGFR >60 ml/min per 1.73 m2): eGFR 30-44 ml/min per 1.73 (aHR, 0.78; 95% CI, 0.70 to 0.87), eGFR 15-29 ml/min per 1.73 m2 (aHR, 0.73; 95% CI, 0.61 to 0.88), and eGFR <15 ml/min per 1.73 m2 (aHR, 0.48; 95% CI, 0.31 to 0.74). CONCLUSIONS In adults with newly diagnosed AF, CKD severity was associated with lower receipt of rate control agents, anticoagulation, and AF procedures. Additional data on efficacy and safety of AF therapies in CKD populations are needed to inform management strategies.
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Affiliation(s)
- Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington
| | - Leila R. Zelnick
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Teresa N. Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Daniel E. Singer
- Clinical Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Alan S. Go
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California,Division of Research, Kaiser Permanente Northern California, Oakland, California,Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California,Departments of Medicine, Stanford University, Palo Alto, California
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