1
|
Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024:ehae176. [PMID: 39210723 DOI: 10.1093/eurheartj/ehae176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
|
2
|
Genovesi S, Camm AJ, Covic A, Burlacu A, Meijers B, Franssen C, Luyckx V, Liakopoulos V, Alfano G, Combe C, Basile C. Treatment strategies of the thromboembolic risk in kidney failure patients with atrial fibrillation. Nephrol Dial Transplant 2024; 39:1248-1257. [PMID: 38816212 PMCID: PMC11288792 DOI: 10.1093/ndt/gfae121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Indexed: 06/01/2024] Open
Abstract
The incidence and prevalence of atrial fibrillation (AF) in patients affected by kidney failure, i.e. glomerular filtration rate <15 ml/min/1.73 m2, is high and probably underestimated. Numerous uncertainties remain regarding how to prevent thromboembolic events in this population because both cardiology and nephrology guidelines do not provide clear recommendations. The efficacy and safety of oral anticoagulant therapy (OAC) in preventing thromboembolism in patients with kidney failure and AF has not been demonstrated for either vitamin K antagonists (VKAs) or direct anticoagulants (DOACs). Moreover, it remains unclear which is more effective and safer, because estimated creatinine clearance <25-30 ml/min was an exclusion criterion in the randomized controlled trials (RCTs). Three RCTs comparing DOACs and VKAs in kidney failure failed to reach the primary endpoint, as they were underpowered. The left atrial appendage is the main source of thromboembolism in the presence of AF. Left atrial appendage closure (LAAC) has recently been proposed as an alternative to OAC. RCTs comparing the efficacy and safety of LAAC versus OAC in kidney failure were terminated prematurely due to recruitment failure. A recent prospective study showed a reduction in thromboembolic events in haemodialysis patients with AF and undergoing LAAC compared with patients taking or not taking OAC. We review current treatment standards and discuss recent developments in managing the thromboembolic risk in kidney failure patients with AF. The importance of shared decision-making with the multidisciplinary team and the patient to consider individual risks and benefits of each treatment option is underlined.
Collapse
Affiliation(s)
- Simonetta Genovesi
- School of Medicine and Surgery, University of Milano-Bicocca, Nephrology Clinic, Monza, Italy
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - A John Camm
- St. George's University of London, London, UK
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center – ‘C.I. Parhon’ University Hospital and 'Grigore T. Popa’ University of Medicine, Iasi, Romania
| | - Alexandru Burlacu
- Nephrology Clinic, Dialysis and Renal Transplant Center – ‘C.I. Parhon’ University Hospital and 'Grigore T. Popa’ University of Medicine, Iasi, Romania
| | - Björn Meijers
- Nephrology Unit, University Hospitals Leuven and Department of Microbiology, Immunology and Organ Transplantation, KU Leuven, Leuven, Belgium
| | - Casper Franssen
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Valerie Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Vassilios Liakopoulos
- Second Department of Nephrology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Gaetano Alfano
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Christian Combe
- Department of Nephrology, CHU de Bordeaux and INSERM U1026, University of Bordeaux, Bordeaux, France
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
| |
Collapse
|
3
|
Hall RK, Kazancıoğlu R, Thanachayanont T, Wong G, Sabanayagam D, Battistella M, Ahmed SB, Inker LA, Barreto EF, Fu EL, Clase CM, Carrero JJ. Drug stewardship in chronic kidney disease to achieve effective and safe medication use. Nat Rev Nephrol 2024; 20:386-401. [PMID: 38491222 DOI: 10.1038/s41581-024-00823-3] [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] [Accepted: 02/22/2024] [Indexed: 03/18/2024]
Abstract
People living with chronic kidney disease (CKD) often experience multimorbidity and require polypharmacy. Kidney dysfunction can also alter the pharmacokinetics and pharmacodynamics of medications, which can modify their risks and benefits; the extent of these changes is not well understood for all situations or medications. The principle of drug stewardship is aimed at maximizing medication safety and effectiveness in a population of patients through a variety of processes including medication reconciliation, medication selection, dose adjustment, monitoring for effectiveness and safety, and discontinuation (deprescribing) when no longer necessary. This Review is aimed at serving as a resource for achieving optimal drug stewardship for patients with CKD. We describe special considerations for medication use during pregnancy and lactation, during acute illness and in patients with cancer, as well as guidance for the responsible use of over-the-counter drugs, herbal remedies, supplements and sick-day rules. We also highlight inequities in medication access worldwide and suggest policies to improve access to quality and essential medications for all persons with CKD. Further strategies to promote drug stewardship include patient education and engagement, the use of digital health tools, shared decision-making and collaboration within interdisciplinary teams. Throughout, we position the person with CKD at the centre of all drug stewardship efforts.
Collapse
Affiliation(s)
- Rasheeda K Hall
- Division of Nephrology, Department of Medicine, and Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | | | | | - Sofia B Ahmed
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lesley A Inker
- Division of Nephrology, Department of Internal Medicine, Tufts Medical Center, Boston, MA, USA
| | | | - Edouard L Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Juan J Carrero
- Medical Epidemiology and Biostatistics, Karolinska Institutet, and Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden.
| |
Collapse
|
4
|
AlTurki A, Marafi M, Dawas A, Joza J, Proietti R, Russo V, Mavrakanas T, Trinh E, Weber C, Suri R, Essebag V, Huynh T. Meta-analysis evaluating apixaban in patients with atrial fibrillation and end-stage renal disease requiring dialysis. J Arrhythm 2024; 40:440-447. [PMID: 38939758 PMCID: PMC11199838 DOI: 10.1002/joa3.13051] [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: 10/29/2023] [Revised: 04/13/2024] [Accepted: 04/21/2024] [Indexed: 06/29/2024] Open
Abstract
Background Warfarin is considered the primary oral anticoagulant for patients with atrial fibrillation and end-stage renal disease (ESRD) requiring dialysis. Although warfarin can offer significant stroke prevention in this population, the accompanying major bleeding risks make warfarin nearly prohibitive. Apixaban was shown to be superior to warfarin in preventing stroke or systemic embolism, with a lower risk of bleeding and mortality in a large, randomized trial of individuals with mostly normal renal function but none with ESRD. Methods We systematically reviewed evidence comparing apixaban versus warfarin for atrial fibrillation in this population, and evaluated outcomes of stroke or systemic embolism, and major bleeding using random-effects models. The main safety outcome was major bleeding, and the main effectiveness outcome was stroke or systemic embolism. Results We found five observational studies of 10 036 patients (2638 receiving apixaban, and 7398 receiving warfarin) meeting inclusion criteria. Pooled analysis demonstrated a significant reduction in major bleeding with apixaban as compared to warfarin (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.42-0.61; p < .0001). Apixaban was also associated with a reduction in intracranial bleeding (OR 0.58, 95% CI 0.37-0.92; p = .02) and in gastrointestinal bleeding (OR 0.61, 95% CI 0.51-0.73; p < .0001). Furthermore, apixaban was associated with a reduction in stroke/systemic embolism (OR 0.64, 95% CI 0.50-0.82; p < .0001). Conclusion Apixaban was associated with superior outcomes and reduced adverse events compared to warfarin in observational studies of patients with atrial fibrillation on dialysis. Randomized controlled studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Ahmed AlTurki
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Mariam Marafi
- Department of NeurologyMontreal Neurological InstituteMontrealQuebecCanada
| | - Ahmed Dawas
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Jacqueline Joza
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Riccardo Proietti
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
| | - Vincenzo Russo
- University of Campania “Luigi Vanvitelli”–Monaldi HospitalNaplesItaly
| | - Thomas Mavrakanas
- Division of NephrologyMcGill University Health CenterMontrealQuebecCanada
| | - Emilie Trinh
- Division of NephrologyMcGill University Health CenterMontrealQuebecCanada
| | - Catherine Weber
- Division of NephrologyMcGill University Health CenterMontrealQuebecCanada
| | - Rita Suri
- Division of NephrologyMcGill University Health CenterMontrealQuebecCanada
| | - Vidal Essebag
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Thao Huynh
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| |
Collapse
|
5
|
Potpara T, Grygier M, Häusler KG, Nielsen-Kudsk JE, Berti S, Genovesi S, Marijon E, Boveda S, Tzikas A, Boriani G, Boersma LVA, Tondo C, De Potter T, Lip GYH, Schnabel RB, Bauersachs R, Senzolo M, Basile C, Bianchi S, Osmancik P, Schmidt B, Landmesser U, Döhner W, Hindricks G, Kovac J, Camm AJ. Practical guide on left atrial appendage closure for the non-implanting physician: an international consensus paper. Europace 2024; 26:euae035. [PMID: 38291925 PMCID: PMC11009149 DOI: 10.1093/europace/euae035] [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: 10/16/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
A significant proportion of patients who suffer from atrial fibrillation (AF) and are in need of thromboembolic protection are not treated with oral anticoagulation or discontinue this treatment shortly after its initiation. This undertreatment has not improved sufficiently despite the availability of direct oral anticoagulants which are associated with less major bleeding than vitamin K antagonists. Multiple reasons account for this, including bleeding events or ischaemic strokes whilst on anticoagulation, a serious risk of bleeding events, poor treatment compliance despite best educational attempts, or aversion to drug therapy. An alternative interventional therapy, which is not associated with long-term bleeding and is as effective as vitamin K anticoagulation, was introduced over 20 years ago. Because of significant improvements in procedural safety over the years, left atrial appendage closure, predominantly achieved using a catheter-based, device implantation approach, is increasingly favoured for the prevention of thromboembolic events in patients who cannot achieve effective anticoagulation. This management strategy is well known to the interventional cardiologist/electrophysiologist but is not more widely appreciated within cardiology or internal medicine. This article introduces the devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. Almost all physicians who care for adult patients will have many with AF. This practical guide, written within guideline/guidance boundaries, is aimed at those non-implanting physicians who may need to refer patients for consideration of this new therapy, which is becoming increasingly popular.
Collapse
Affiliation(s)
- Tatjana Potpara
- Medical Faculty, University of Belgrade, Belgrade, Serbia
- University Clinical Centre of Serbia, Belgrade, Serbia
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University School of Medical Sciences, Poznan, Poland
| | - Karl Georg Häusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | | | - Sergio Berti
- Ospedale del Cuore, Fondazione CNR Regione Toscana G. Monasterio, Pisa, Italy
| | - Simonetta Genovesi
- School of Medicine and Surgery, University of Milano-Bicocca, Nephrology Clinic, Monza, Italy
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Eloi Marijon
- Division of Cardiology, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - Serge Boveda
- Cardiology, Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Cardiologie Clinique Pasteur, Brussels University VUB, Brussels, Belgium
| | - Apostolos Tzikas
- Ippokrateio Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Structural and Congenital Heart Disease, European Interbalkan Medical Centre, Thessaloniki, Greece
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Lucas V A Boersma
- Cardiology Department, St. Antonius Hospital Nieuwegein/Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Claudio Tondo
- Centro Cardiologico Monzino, IRCCS, Department of Clinical Electrophysiology & Cardiac Pacing, Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Tom De Potter
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Rupert Bauersachs
- Cardioangiology Center Bethanien CCB, Frankfurt, Germany
- Center for Vascular Research, Munich, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Carlo Basile
- Division of Nephrology, Miull General Hospital, Acquaviva delle Fonti, Italy
- EuDial Working Group of the European Renal Association, Acquaviva delle Fonti, Italy
| | - Stefano Bianchi
- Nephrology and Dialysis Unit, ASL Toscana NordOvest, Livorno, Italy
| | - Pavel Osmancik
- Department of Cardiology, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum Charité, Charité University Medicine, Berlin
| | - Wolfram Döhner
- Berlin Institute of Health-Center for Regenerative Therapies, Berlin, Germany
- Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK)- partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | | | - Jan Kovac
- Leicester NIHR BRU, University of Leicester, Glenfield Hospital, Leicester, UK
| | - A John Camm
- Genetic and Cardiovascular Sciences Institute, Cardiology Academic Group, St. George’s University of London, Cranmer Terrace, London SW190RE, UK
| |
Collapse
|
6
|
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.
Collapse
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.
| |
Collapse
|
7
|
Welander F, Renlund H, Dimény E, Holmberg H, Själander A. Warfarin treatment quality and outcomes in patients with non-valvular atrial fibrillation and CKD G3-G5D. Thromb Res 2023; 229:131-138. [PMID: 37453255 DOI: 10.1016/j.thromres.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 07/02/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Warfarin treatment quality is calculated as time in therapeutic range (TTR). TTR ≥ 70 % is considered reducing the risk of adverse events for patients with atrial fibrillation (AF). The association of TTR and adverse events in chronic kidney disease (CKD) is however poorly investigated. The aim is to explore this further. MATERIALS AND METHODS Swedish cohort study based on national healthcare registers between 2009 and 2018, including Swedish Renal Registry, Swedish Stroke Register and AuriculA - the Swedish national quality register for AF and anticoagulation. Investigating the effect of individual TTR (iTTR) and iTTR ≥ 70 % versus <70 % on the risk of ischemic stroke, major bleeding and death for patients with CKD GFR category 3-5 (G3-G5) including patients on dialysis (G5D) and non-valvular AF (NVAF). RESULTS Of 2379 included patients 21.9 % had G3, 47.5 % G4, 10.8 % G5 and 19.8 % G5D. TTR in G3 was 75.6 %, G4 72.2 %, G5 67.6 % and G5D 62.0 %. Increase by 10 percentage points iTTR conferred lower risk of major bleeding, ischemic stroke and death for all patients (hazard ratio 0.91 (95 % Confidence interval 0.87-0.94), 0.92 (0.85-0.99) and 0.88 (0.85-0.90)). iTTR≥ 70 % versus <70 % was associated with lower risk of bleeding and death in all patients (0.63 (0.51-0.77) and (0.51 (0.43-0.61)), and a non-significant tendency towards lower stroke risk (0.67 (0.43-1.06)). CONCLUSIONS Warfarin treatment quality worsens with decreasing GFR. Higher iTTR confers lower risk of bleeding, ischemic stroke and death in patients with NVAF and G3-G5D. iTTR ≥ 70 % was associated with better safety profile. Close monitoring of patients with CKD on warfarin is recommended.
Collapse
Affiliation(s)
- Frida Welander
- Department of Public Health and Clinical Medicine, Department of Research and Development-Sundsvall, Umeå University, Lasarettsvägen 21, S-85643 Sundsvall, Sweden.
| | - Henrik Renlund
- Uppsala Clinical Research Centre, Uppsala University, Uppsala Science Park, Hubben, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden
| | - Emöke Dimény
- Department of Public Health and Clinical medicine, Umeå University, 901 87 Umeå, Sweden
| | - Henrik Holmberg
- Department of Epidemiology and Global Health, Umeå University, 901 87 Umeå, Sweden
| | - Anders Själander
- Department of Epidemiology and Global Health, Umeå University, 901 87 Umeå, Sweden
| |
Collapse
|
8
|
Trevisan M, Hjemdahl P, Clase CM, de Jong Y, Evans M, Bellocco R, Fu EL, Carrero JJ. Cardiorenal Outcomes Among Patients With Atrial Fibrillation Treated With Oral Anticoagulants. Am J Kidney Dis 2023; 81:307-317.e1. [PMID: 36208798 DOI: 10.1053/j.ajkd.2022.07.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 07/31/2022] [Indexed: 11/06/2022]
Abstract
RATIONALE & OBJECTIVE Direct oral anticoagulants (DOACs) have progressively replaced vitamin K antagonists (VKAs) for stroke prevention in patients with nonvalvular atrial fibrillation (AF). DOACs cause fewer bleeding complications, but their other advantages, particularly related to kidney outcomes, remain inconclusive. We studied the risks of chronic kidney disease (CKD) progression and acute kidney injury (AKI) after DOAC and VKA administration for nonvalvular AF. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Cohort study of Swedish patients enrolled in the Stockholm Creatinine Measurements (SCREAM) project with a diagnosis of nonvalvular AF during 2011-2018. EXPOSURE Initiation of DOAC or VKA treatment. OUTCOME Primary outcomes were CKD progression (composite of >30% estimated glomerular filtration rate [eGFR] decline and kidney failure) and AKI (by diagnosis or KDIGO-defined transient creatinine elevations). Secondary outcomes were death, major bleeding, and the composite of stroke and systemic embolism. ANALYTICAL APPROACH Propensity score weighted Cox regression was used to balance 50 baseline confounders. Sensitivity analyses included falsification end points, subgroups, and estimation of per-protocol effects. RESULTS We included 32,699 patients (56% initiated DOAC) who were observed for a median of 3.8 years. Their median age was 75 years, 45% were women, and 27% had an eGFR <60mL/min/1.73m2. The adjusted HRs for DOAC versus VKA were 0.87 (95% CI, 0.78-0.98) for the risk of CKD progression and 0.88 (95% CI, 0.80-0.97) for AKI. HRs were 0.77 (95% CI, 0.67-0.89) for major bleeding, 0.93 (95% CI, 0.78-1.11) for the composite of stroke and systemic embolism, and 1.04 (95% CI, 0.95-1.14) for death. The results were similar across subgroups of age, sex, and baseline eGFR when restricting to patients at high risk for thromboembolic events and when censoring follow up at treatment discontinuation or change in type of anticoagulation. LIMITATIONS Missing information on time in therapeutic range and treatment dosages. CONCLUSIONS Among patients with nonvalvular AF treated in routine clinical practice compared with VKA use, DOAC use was associated with a lower risk of CKD progression, AKI, and major bleeding but a similar risk of the composite of stroke, systemic embolism, or death.
Collapse
Affiliation(s)
- Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Campus Solna, Karolinska Institutet, Stockholm, Sweden
| | - Paul Hjemdahl
- Clinical Epidemiology Unit/Clinical Pharmacology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Ype de Jong
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Marie Evans
- Department of Clinical Science Intervention and Technology, Hospital Huddinge, Karolinska University, Huddinge, Sweden
| | - Rino Bellocco
- Department of Medical Epidemiology and Biostatistics, Campus Solna, Karolinska Institutet, Stockholm, Sweden; Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Edouard L Fu
- Department of Medical Epidemiology and Biostatistics, Campus Solna, Karolinska Institutet, Stockholm, Sweden; Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Campus Solna, Karolinska Institutet, Stockholm, Sweden; Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.
| |
Collapse
|
9
|
Montomoli M, Roca L, Rivera M, Fernandez-Prado R, Redondo B, Camacho R, Moyano C, Pampa S, Gonzalez A, Casas J, Kislikova M, Sanchez Horrillo A, Cabrera Cárdena A, Quiroga B, Rabasco C, Piqueras S, Suso A, Reque J, Villa J, Ojeda R, Arroyo D. Oral Anticoagulation in Patients with Chronic Kidney Disease and Non-Valvular Atrial Fibrillation: The FAERC Study. Healthcare (Basel) 2022; 10:healthcare10122566. [PMID: 36554089 PMCID: PMC9778700 DOI: 10.3390/healthcare10122566] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 11/30/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in patients with chronic kidney disease (CKD), and its presence is associated with a higher risk of stroke and mortality. MATERIAL AND METHODS The FAERC study performed a retrospective multicentre analysis of historical cohorts in which data were collected from arrhythmia diagnosis onwards. RESULTS We analysed a Spanish cohort of 4749 patients with CKD (mean eGFR 33.9 mL/min) followed up in the nephrology clinic, observing a 12.2% prevalence of non-valvular AF. In total, 98.6% of these patients were receiving anticoagulant treatment, mainly with coumarins (79.7%). Using direct-acting oral anticoagulants (DOACs) was associated with fewer cerebrovascular events than using acenocoumarol, but in contrast with other studies, we could not corroborate the association of risk of bleeding, coronary events, or death with a type of anticoagulant prescribed. CONCLUSIONS Atrial fibrillation is highly prevalent in renal patients. Direct-acting anticoagulants seem to be associated with fewer ischemic-embolic complications, with no differences in bleeding, coronary events, or mortality rates.
Collapse
Affiliation(s)
- Marco Montomoli
- Nephrology Department, Hospital Clínico Universitario de Valencia, Av. Blasco Ibañez 17, 46010 Valencia, Spain
- Correspondence:
| | - Lourdes Roca
- Nephrology Department, Hospital Universitario de La Plana, 12540 Villarreal, Spain
| | - Mariana Rivera
- Nephrology Department, Hospital Universitario Virgen de la Macarena, 41009 Sevilla, Spain
| | - Raul Fernandez-Prado
- Nephrology Department, Hospital Universitario Fundación Jiménez Díaz, 28040 Madrid, Spain
| | - Beatriz Redondo
- Nephrology Department, Hospital Universitario de Cruces, 48903 Bilbao, Spain
| | - Rosa Camacho
- Nephrology Department, Hospital Universitario Severo Ochoa, 28914 Leganes, Spain
| | - Cayetana Moyano
- Nephrology Department, Hospital Universitario Reina Sofía, 14004 Córdoba, Spain
| | - Saul Pampa
- Nephrology Department, Hospital Universitario Rey Juan Carlos, 28933 Móstoles, Spain
| | - Angela Gonzalez
- Nephrology Department, Hospital Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - Juan Casas
- Nephrology Department, Hospital Comarcal Francesc de Borja, 46702 Gandía, Spain
| | - Maria Kislikova
- Nephrology Department, Hospital Universitario Marqués de Valdecilla, 39008 Santander, Spain
| | - Ana Sanchez Horrillo
- Nephrology Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain
| | | | - Borja Quiroga
- Nephrology Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain
| | - Cristina Rabasco
- Nephrology Department, Hospital Universitario Reina Sofía, 14004 Córdoba, Spain
| | - Sara Piqueras
- Nephrology Department, Complejo Hospitalario Universitario de Albacete, 02006 Albacete, Spain
| | - Andrea Suso
- Nephrology Department, Hospital Universitario Severo Ochoa, 28914 Leganes, Spain
| | - Javier Reque
- Nephrology Department, Hospital General Universitario de Castellón, 12004 Castelló, Spain
| | - Juan Villa
- Nephrology Department, Hospital Universitario de Badajoz, 06080 Badajoz, Spain
| | - Raquel Ojeda
- Nephrology Department, Hospital Universitario Reina Sofía, 14004 Córdoba, Spain
| | - David Arroyo
- Nephrology Department, Hospital Universitario Gregorio Marañón, 28007 Madrid, Spain
| |
Collapse
|
10
|
Katada Y, Nakagawa S, Itohara K, Suzuki T, Kato R, Endo H, Sugimoto M, Yonezawa A, Nakagawa T, Ohsumi A, Nakajima D, Date H, Terada T. Association between time in therapeutic range of tacrolimus blood concentration and acute rejection within the first three months after lung transplantation. J Pharm Health Care Sci 2022; 8:25. [PMID: 36180948 PMCID: PMC9526258 DOI: 10.1186/s40780-022-00256-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tacrolimus is a key drug in immunosuppressive therapy following lung transplantation. The blood tacrolimus levels are likely to fluctuate in the early postoperative period, and failure to maintain the tacrolimus trough level in target ranges is a risk factor for rejection. However, there is little information about the relationship between the time in therapeutic range (TTR) of the tacrolimus trough level (tacrolimus TTR) and clinical outcomes. This study aimed to evaluate the association between tacrolimus TTR and acute rejection (AR) within the first three months after lung transplantation. METHODS This was a retrospective study of patients who underwent lung transplantation at a single center. The target tacrolimus trough levels were 10-15 ng/mL, and tacrolimus TTR was calculated using the Rosendaal method. The cut-off value of the tacrolimus TTR was estimated by receiver operating characteristic analysis based on AR. RESULTS The study included 90 patients. AR was observed in 26 patients. In this study, ''early-AR'' was defined as any AR within 2 weeks post-transplant (n = 22) and ''late-AR'' was defined as any AR after 1-month post-transplant (n = 4). For early AR, the relationship between tacrolimus TTR and the onset of AR was examined. There were no differences in the tacrolimus TTR between the early-AR group and non-AR group (35.7 ± 22.4 vs 31.5 ± 19.9%, P = 0.416). For late-AR, the relationship with tacrolimus TTR was examined every 10 d. The tacrolimus TTR during postoperative days (POD) 21-30 and POD 31-onset was significantly lower in the late-AR group than the no-AR group (50.0 ± 7.1 vs. 71.8 ± 18.0% and 37.0 ± 26.6 vs. 68.9 ± 31.5%, P < 0.05, respectively). The cutoff value of the tacrolimus TTR during POD 21-30 was estimated as 55.0%. CONCLUSIONS Our findings suggest that a lower tacrolimus TTR is a predictor of late AR. A tacrolimus TTR of 55% or higher is necessary to reduce the risk of AR during this period after lung transplantation.
Collapse
Affiliation(s)
- Yoshiki Katada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Shunsaku Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Takuya Suzuki
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Ryota Kato
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Hiroki Endo
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Mitsuhiro Sugimoto
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Takayuki Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Daisuke Nakajima
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Kyoto, Sakyo-ku, 606-8507, Japan.
| |
Collapse
|
11
|
Batra G, Modica A, Renlund H, Larsson A, Christersson C, Held C. Oral anticoagulants, time in therapeutic range and renal function over time in real-life patients with atrial fibrillation and chronic kidney disease. Open Heart 2022; 9:openhrt-2022-002043. [PMID: 36104096 PMCID: PMC9476150 DOI: 10.1136/openhrt-2022-002043] [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: 04/19/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
Aims To describe the use of warfarin and direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) and chronic kidney disease (CKD), to evaluate changes in renal function over time and predictors of rapid decline, and to describe time in therapeutic range (TTR) and predictors of poor TTR among patients on warfarin. Methods and results Using data from AuriculA, the Swedish oral anticoagulation registry, patients with AF on warfarin or DOAC were identified between 2013 and 2018 (N=6567). Estimated glomerular filtration rate (eGFR) was calculated and categorised into normal (≥90 mL/min/1.73 m2), mild CKD (60–89 mL/min/1.73 m2), moderate CKD (30–59 mL/min/1.73 m2), severe CKD (15–29 mL/min/1.73 m2) and end-stage CKD (<15 mL/min/1.73 m2)/dialysis. TTR was estimated using international normalised ratio (INR) measurements. Predictors of eGFR decline over time and of poor TTR were estimated using regression analysis. Between 2013 and 2018, use of DOAC increased from 9.2% to 89.3%, with a corresponding decline in warfarin. A similar trend was observed in patients with mild to moderate CKD, while DOAC over warfarin increased slower among patients with severe to end-stage CKD/dialysis. In patients treated with warfarin, the median TTR was 77.1%. Worse TTR was observed among patients with severe CKD (70.0%) and end-stage CKD/dialysis (67.5%). A gradual annual decline in eGFR was observed (−1.1 mL/min/1.73 m2), with a more rapid decline among patients with older age, female sex, diabetes mellitus and/or heart failure. Conclusion In patients with AF, use of DOAC has steadily increased across different CKD stages, but not in patients with severe to end-stage CKD/dialysis despite these patients having poor INR control. Patients with AF have a gradual decline in renal function, with a more rapid decline among a subgroup of patients.
Collapse
Affiliation(s)
- Gorav Batra
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden .,Uppsala Clinical Research Center, Uppsala, Sweden
| | | | | | - Anders Larsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | | | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala, Sweden
| |
Collapse
|
12
|
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: 4] [Impact Index Per Article: 2.0] [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.
Collapse
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
| |
Collapse
|
13
|
Benini Tapias J, Flores-Umanzor E, Cepas-Guillén PL, Regueiro A, Sanchís L, Broseta JJ, Cases A, Freixa X. Prognostic impact of the presence of chronic kidney disease on percutaneous left trial appendage closure for atrial fibrillation: A single center experience. Nefrologia 2022; 42:290-300. [PMID: 36210618 DOI: 10.1016/j.nefroe.2022.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Percutaneous left atrial appendage closure (LAAC) has been proposed as an alternative to anticoagulation therapy in patients with nonvalvular atrial fibrillation (NVAF) to decrease the thromboembolic risk, while avoiding the risks of chronic anticoagulation. This option may be attractive in patients with NVAF and chronic kidney disease (CKD), since they exhibit both high thromboembolic and bleeding risks. OBJECTIVE To evaluate the prognostic impact of the presence of CKD in patients with atrial fibrillation undergoing LAAC peri-procedure and during the follow-up as compared with patients with preserved renal function. METHODS Retrospective, observational study that included 124 consecutive patients with atrial fibrillation undergoing LAAC in a university hospital, and the results were evaluated according to the baseline renal function of the patients. RESULTS The median age was 75,5 years (IQR 67,6-80) and 62,1% were men, the median of CHA2DS2-Vasc and HASBLED scores was 4 (IQR 3-4) for both scores. Up to 57,3% of the total sample had CKD. Baseline characteristics were similar between groups, but CKD patients were older and had a higher HASBLED score. During the procedure, no thromboembolic, bleeding events, or deaths were observed. Combining the time of hospitalization and follow-up, no significant differences were observed between groups in the annual rate of thromboembolic events (0.97/100 patient-years [100PY] vs 4.06/100PY, P =,09), but there was a higher rate of bleeding events (5.67/100PY vs. 13.3/100PY, P =,033) and mortality among CKD patients (6.50/100PY vs. 17.2/100PY, P =,009), with an odds ratio of 2.711 (95% CI 1,96-6,95). In the multivariate analysis a preserved eGFR was independently associated with a lower mortality risk. CONCLUSIONS LAAC is a valid alternative to oral anticoagulation in patients with CKD and atrial fibrillation, with a low rate of peri- and post-procedure complications, although CKD patients exhibited a higher risk of bleeding and mortality during the follow-up. However, these higher rates may not be necessarily related to the procedure.
Collapse
Affiliation(s)
| | | | | | - Ander Regueiro
- Servicio de Cardiología, Hospital Clinic, Barcelona, Spain
| | - Laura Sanchís
- Servicio de Cardiología, Hospital Clinic, Barcelona, Spain
| | - José Jesús Broseta
- Departament de Cirurgia i Especialitats Medicoquirurgiques, Universitat de Barcelona, Barcelona, Spain
| | - Aleix Cases
- Departament de Medicina, Universitat de Barcelona, Barcelona, Spain.
| | - Xavier Freixa
- Servicio de Cardiología, Hospital Clinic, Barcelona, Spain
| |
Collapse
|
14
|
Carrero JJ, Elinder CG. The Stockholm CREAtinine Measurements (SCREAM) project: Fostering improvements in chronic kidney disease care. J Intern Med 2022; 291:254-268. [PMID: 35028991 DOI: 10.1111/joim.13418] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
SCREAM (Stockholm CREAtinine Measurements project) was initiated in 2010 in collaboration with the healthcare provider of Stockholm County healthcare to quantify potential medication errors, estimate the burden of chronic kidney disease (CKD) and to illustrate the value of incorporating measures of kidney function into the medical decision process. Because most patients are unaware of their CKD and diagnoses are seldom issued, SCREAM took advantage of the commonness of serum/plasma creatinine testing, which can be used to estimate the glomerular filtration rate (eGFR) and classify the stage of CKD severity. SCREAM is periodically updated, and at present contains healthcare information of all residents in Stockholm region during 2006-2019 (about 3 million people), enriched with a broad range of laboratory measurements for those in whom creatinine or albuminuria has been measured (about 1.8 million people). This health information was linked with national administrative and quality registries via the unique personal identification number of each Swedish citizen, conforming the richest characterization in Sweden of the population's journey through health and disease. This review discusses the context of its creation, strengths and weakness, key findings and plans for the future. We summarize our findings related to the burden of CKD in Sweden, its adverse health risks (such as risk of infections, cancer or dementia) and how underlying kidney function alters the risk-benefit ratio of common medications. Results have had clinical impact and demonstrate the importance of population-based research in the spectrum of clinical research to improve health.
Collapse
Affiliation(s)
- Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Carl Gustaf Elinder
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
15
|
Dry Needling and Antithrombotic Drugs. Pain Res Manag 2022; 2022:1363477. [PMID: 35035647 PMCID: PMC8759918 DOI: 10.1155/2022/1363477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 12/21/2021] [Indexed: 11/22/2022]
Abstract
Many clinicians increasingly use dry needling in clinical practice. However, whether patients' intake of antithrombotic drugs should be considered as a contraindication for dry needling has not been investigated to date. As far as we know, there are no publications in analyzing the intake of antiplatelet or anticoagulant agents in the context of dry needling techniques. A thorough analysis of existing medications and how they may impact various needling approaches may contribute to improved evidence-informed clinical practice. The primary purpose of this paper is to review the current knowledge of antithrombotic therapy in the context of dry needling. In addition, reviewing guidelines of other needling approaches, such as electromyography, acupuncture, botulinum toxin infiltration, and neck ultrasound-guided fine-needle aspiration biopsy, may provide specific insights relevant for dry needling. Based on published data, taking antithrombotic medication should not be considered an absolute contraindication for dry needling techniques. As long as specific dry needling and individual risks are properly considered, it does not change the risk and safety profile of dry needling. Under specific circumstances, the use of ultrasound guidance is recommended when available.
Collapse
|
16
|
Defoe K, Wichart J, Leung K. Time in Therapeutic Range Using a Nomogram for Dose Adjustment of Warfarin in Patients on Hemodialysis With Atrial Fibrillation. Can J Kidney Health Dis 2021; 8:20543581211046079. [PMID: 34552757 PMCID: PMC8450544 DOI: 10.1177/20543581211046079] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/03/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Patients treated with hemodialysis and prescribed warfarin typically have lower time in therapeutic range (TTR) compared to the general population. This may result in less benefit or increased risk of over anticoagulation in these patients. Objective: To assess effectiveness of use of an electronic nomogram for the management of warfarin therapy in patients treated with hemodialysis. Design: Retrospective chart review. Setting: Adult patients treated with hemodialysis. Patients: Patients on hemodialysis receiving warfarin for the management of atrial fibrillation (AF) with therapy managed by nursing led electronic nomogram. Measurements: Time in therapeutic range (as fraction and Rosendaal). Methods: Retrospective chart review over 1 year of international normalized ratio (INR) results was completed, and TTR was calculated. Comparison of patients with TTR greater than 60% to those less than 60% was completed using chi-square analysis. Results: Of 43 patients with warfarin therapy managed by the nomogram, the mean TTR was 55.2% (calculated by fraction method) or 61.2% (calculated by Rosendaal method). More than half of the patients (63.5%) had moderate to good control, defined as TTR greater than 60%. Female sex, liver disease, or history of substance use and more medication holds were associated with lower TTR. Limitations: Small sample size and retrospective nature of review. Conclusions: The results of this review supports the use of an electronic, nursing-led nomogram for the maintenance management of warfarin therapy in stable patients treated with hemodialysis, as use results in TTR greater than 60% for more than half of patients.
Collapse
Affiliation(s)
- Kimberly Defoe
- Alberta Health Services - Department of Pharmacy, Calgary, AB, Canada
| | - Jenny Wichart
- Alberta Health Services - Department of Pharmacy, Calgary, AB, Canada
| | - Kelvin Leung
- Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada
| |
Collapse
|
17
|
Cases A, Gomez P, Broseta JJ, Perez Bernat E, Arjona Barrionuevo JDD, Portolés JM, Gorriz JL. Non-valvular Atrial Fibrillation in CKD: Role of Vitamin K Antagonists and Direct Oral Anticoagulants. A Narrative Review. Front Med (Lausanne) 2021; 8:654620. [PMID: 34604247 PMCID: PMC8484537 DOI: 10.3389/fmed.2021.654620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in chronic kidney disease (CKD), with a close bidirectional relationship between the two entities. The presence of CKD in AF increases the risk of thromboembolic events, mortality and bleeding. Vitamin K antagonists (VKA) have been the mainstay of treatment for the prevention of thromboembolic events in AF until recently, with confirmed benefits in AF patients with stage 3 CKD. However, the risk-benefit profile of VKA in patients with AF and stages 4-5 CKD is controversial due to the lack of evidence from randomized controlled trials. Treatment with VKA in CKD patients has been associated with conditions such as poorer anticoagulation quality, increased risk of bleeding, faster progression of vascular/valvular calcification and higher risk of calciphylaxis. Direct oral anticoagulants (DOACs) have shown equal or greater efficacy in stroke/systemic embolism prevention, and a better safety profile than VKA in post-hoc analysis of the pivotal randomized controlled trials in patients with non-valvular AF and stage 3 CKD, yet evidence of its risk-benefit profile in more advanced stages of CKD is scarce. Observational studies associate DOACs with a good safety/effectiveness profile compared to VKA in non-dialysis CKD patients. Further, DOACs have been associated with a lower risk of acute kidney injury and CKD development/progression than VKA. This narrative review summarizes the evidence of the efficacy and safety of warfarin and DOACs in patients with AF at different CKD stages, as well as their effects on renal function, vascular/valvular calcification and bone health.
Collapse
Affiliation(s)
- Aleix Cases
- Departament de Medicina, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Pablo Gomez
- Unidad de Factores de Riesgo Vascular, Servicio de Nefrología, Hospital Universitario de Jerez, Jerez de la Frontera, Spain
| | | | | | | | | | - Jose Luis Gorriz
- Departament de Medicina, Universitat de Valencia, Valencia, Spain
- Hospital Clínico Universitario de Valencia, Valencia, Spain
- Instituto de Investigación del Hospital Clinico Universitario, Valencia (INCLIVA), Valencia, Spain
| |
Collapse
|
18
|
Benini Tapias J, Flores-Umanzor E, Cepas-Guillén PL, Regueiro A, Sanchís L, Broseta JJ, Cases A, Freixa X. Prognostic impact of the presence of chronic kidney disease on percutaneous left trial appendage closure for atrial fibrillation: A single center experience. Nefrologia 2021; 42:S0211-6995(21)00130-2. [PMID: 34362613 DOI: 10.1016/j.nefro.2021.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Percutaneous left atrial appendage closure (LAAC) has been proposed as an alternative to anticoagulation therapy in patients with nonvalvular atrial fibrillation to decrease the thromboembolic risk, while avoiding the risks of chronic anticoagulation. This option may be attractive in patients with nonvalvular atrial fibrillation and chronic kidney disease (CKD), since they exhibit both high-thromboembolic and bleeding risks. OBJECTIVE To evaluate the prognostic impact of the presence of CKD in patients with atrial fibrillation undergoing LAAC peri-procedure and during the follow-up as compared with patients with preserved renal function. METHODS Retrospective, observational study that included 124 consecutive patients with atrial fibrillation undergoing LAAC in a university hospital, and the results were evaluated according to the baseline renal function of the patients. RESULTS The median age was 75.5 years (IQR 67.6-80) and 62.1% were men, the median of CHA2DS2-Vasc and HASBLED scores was 4 (IQR 3-4) for both scores. Up to 57.3% of the total sample had CKD. Baseline characteristics were similar between groups, but CKD patients were older and had a higher HASBLED score. During the procedure, no thromboembolic, bleeding events, or deaths were observed. Combining the time of hospitalization and follow-up, no significant differences were observed between groups in the annual rate of thromboembolic events (0.97/100 patient-years [100PY] vs. 4.06/100PY, p=.09), but there was a higher rate of bleeding events (5.67/100PY vs. 13.3/100PY, p=.033) and mortality among CKD patients (6.50/100PY vs. 17.2/100PY, p=.009), with an odds ratio of 2.711 (95% CI 1.96-6.95). In the multivariate analysis, a preserved eGFR was independently associated with a lower mortality risk. CONCLUSIONS LAAC is a valid alternative to oral anticoagulation in patients with CKD and atrial fibrillation, with a low-rate of peri- and post-procedure complications, although CKD patients exhibited a higher risk of bleeding and mortality during the follow-up. However, these higher rates may not be necessarily related to the procedure.
Collapse
Affiliation(s)
| | | | | | - Ander Regueiro
- Servicio de Cardiología, Hospital Clinic, Barcelona, España
| | - Laura Sanchís
- Servicio de Cardiología, Hospital Clinic, Barcelona, España
| | - José Jesús Broseta
- Departament de Cirurgia i Especialitats Medicoquirúrgiques, Universitat de Barcelona, Barcelona, España
| | - Aleix Cases
- Departament de Medicina, Universitat de Barcelona, Barcelona, España.
| | - Xavier Freixa
- Servicio de Cardiología, Hospital Clinic, Barcelona, España
| |
Collapse
|
19
|
Ding WY, Lip GYH, Shantsila A. Relationship between Chronic Kidney Disease, Time-in-Therapeutic Range, and Adverse Outcomes in Atrial Fibrillation: A post hoc Analysis from the AMADEUS Trial. Cerebrovasc Dis 2021; 51:29-35. [PMID: 34320504 DOI: 10.1159/000517608] [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: 05/07/2021] [Accepted: 06/02/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The benefit of anticoagulation therapy in atrial fibrillation (AF) and chronic kidney disease (CKD) remains controversial. We aimed to evaluate the impact of renal function on the quality of anticoagulation control, and the effects of both these factors on outcomes in AF. METHODS Post hoc analysis of the AMADEUS trial. Trial-related outcomes were adjudicated and we studied the composite of first stroke/major bleeding/all-cause mortality, ischaemic stroke, major bleeding, all-cause mortality, and cardiovascular mortality. RESULTS We included 2,282 vitamin K antagonist (VKA)-treated patients {n = 787 (34.5%) females; median age 72 (interquartile ranges [IQR] 64-77) years}. Median follow-up was 365 (IQR 189-460) days. There were 1,922 (84.2%) non-CKD and 360 (15.8%) CKD patients. Renal function was inversely correlated with time-in-therapeutic range (r = -0.047, p = 0.025). There was no statistical difference in terms of crude study outcomes based on renal function. Multivariable regression analysis demonstrated that moderate renal failure with estimated glomerular filtration rate of less than 60 mL/min/1.73 m2 (p = 0.032) and percentage of time-in-therapeutic range (p = 0.011) were independent predictors for the composite outcome of stroke, major bleeding, and all-cause mortality. CONCLUSION Deteriorated renal function has a small negative impact on the quality of anticoagulation control with VKA which is linked to poor outcomes in AF. However, moderate renal failure itself was an independent risk factor for increased risk of stroke, major bleeding, and all-cause mortality amongst patients with AF.
Collapse
Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Alena Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| |
Collapse
|
20
|
Botto G, Ameri P, Cappellari M, Dentali F, Ferri N, Parrini I, Porto I, Squizzato A, Camporese G. Unmet Clinical Needs in Elderly Patients Receiving Direct Oral Anticoagulants for Stroke Prevention in Non-valvular Atrial Fibrillation. Adv Ther 2021; 38:2891-2907. [PMID: 34019247 PMCID: PMC8189975 DOI: 10.1007/s12325-021-01769-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 04/30/2021] [Indexed: 12/11/2022]
Abstract
Vitamin K antagonists have been used for many years as the treatment of choice for long-term oral anticoagulation in patients with non-valvular atrial fibrillation. Unfortunately, the use of those drugs in the real-world setting, particularly among elderly patients, is suboptimal because of their limitations in management. Therefore, many patients were not adequately anticoagulated. Direct oral anticoagulants have been demonstrated to overcome almost all the limitations derived from the use of vitamin K antagonists. Direct oral anticoagulants are at least as effective as vitamin K antagonists in preventing thromboembolic events in patients with non-valvular atrial fibrillation and safer in reducing the risk of intracranial haemorrhage and all-cause mortality. However, as a result of the strict inclusion and exclusion criteria applied to patients, data coming from randomized controlled trials might not apply to the general population. Furthermore, elderly patients were scarcely represented in randomized controlled trials with direct oral anticoagulants. Therefore in elderly patients with non-valvular atrial fibrillation, unmet clinical needs still exist. This review article highlights some of them and provides potential answers based on the results coming from randomized clinical trials, real-world data, and the authors' clinical experience.
Collapse
Affiliation(s)
- Gianluca Botto
- Cardiologia Elettrofisiologia, ASST Rhodense, Rho and Garbagnate Hospitals, Milan, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, Department of Internal Medicine, IRCCS Ospedale Policlinico, University of Genova, Genoa, Italy
| | - Manuel Cappellari
- Stroke Unit, Department of Neurosciences, University Hospital of Verona, Verona, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Nicola Ferri
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Padua, Italy
| | - Iris Parrini
- S.C. Cardiologia, Ospedale Mauriziano Umberto I, Turin, Italy
| | - Italo Porto
- Clinic of Cardiovascular Diseases, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino Genoa-Italian Cardiovascular Network, Genoa, Italy
| | | | - Giuseppe Camporese
- Angiology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy.
| |
Collapse
|
21
|
Chantrarat T, Krittayaphong R. The Clinical Outcomes of Different eGFR Strata and Time in Therapeutic Range in Atrial Fibrillation Patients with Chronic Kidney Disease: A Nationwide Cohort Study. Curr Probl Cardiol 2021; 46:100838. [PMID: 33992427 DOI: 10.1016/j.cpcardiol.2021.100838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 03/06/2021] [Indexed: 10/21/2022]
Abstract
Chronic kidney disease (CKD) is associated with increased risk of stroke, major bleeding, morbidity and overall mortality in atrial fibrillation patients. The aim of this study is to demonstrate the effect of different eGFR strata and the TTR on clinical outcomes in AF patients with CKD.NVAF patients were consecutively enrolled from hospitals across Thailand. eGFR were categorized into three different eGFR categories; eGFR >60, 30-59 and <30 mL/min/1.73 m2. TTR values were also categorized into TTR >75%, TTR 60-75 and TTR <60%. We identified 1,739 patients who received warfarin. Among patients who acquired TTR<60, those with eGFR <30 ml/min/1.73 m2 demonstrated the highest stroke/SSE rate of 8.5% (P<0.001). Patients with eGFR <30 ml/min/1.73 m2, in addition to the presence of TTR<60, were at the highest risk to developing major bleeding with the rate of 17.9% (p <0.001). However, intracranial hemorrhage (ICH) appeared towards increasing rate with the combination of eGFR at even <60 ml/min/1.73 m2 and TTR <60. Death was also considerably high with the rate of 17.9% in patients with the combination of TTR <60 and eGFR <30 ml/min/1.73 m2. Severe CKD resulted in higher risks of stroke/SSE, major bleeding and death in patients with low TTR. Patients with TTR >60, especially TTR >75%, is associated with reduced risk of stroke/SSE, major bleeding and death irrespective of eGFR level. The combination of low TTR <60 and eGFR level less than 60 ml/min/1.73 m2 substantially increased risks of all cardiovascular outcomes.
Collapse
Affiliation(s)
- Thoranis Chantrarat
- Division of Cardiology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand.
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| |
Collapse
|
22
|
Weir MR, Ashton V, Moore KT, Shrivastava S, Peterson ED, Ammann EM. Rivaroxaban versus warfarin in patients with nonvalvular atrial fibrillation and stage IV-V chronic kidney disease. Am Heart J 2020; 223:3-11. [PMID: 32112872 DOI: 10.1016/j.ahj.2020.01.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/13/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is limited evidence on the effectiveness and safety of direct-acting oral anticoagulants in patients with nonvalvular atrial fibrillation (NVAF) and advanced chronic kidney disease (CKD). This study compared the risks of ischemic stroke/systemic embolism (ISSE) and major bleeding in patients with NVAF and stage IV-V CKD treated with rivaroxaban or warfarin. METHODS Patients with NVAF and stage IV-V CKD who initiated rivaroxaban or warfarin treatment between November 2011 and June 2018 were selected from the Optum® Deidentified Electronic Health Record Database. Propensity score matching was used to balance rivaroxaban and warfarin patients on 112 measured baseline covariates. ISSE and major bleeding events over 2 years following treatment initiation were ascertained with validated end point definitions. Outcomes were analyzed as time-to-event data using Kaplan-Meier survival estimators and Cox regression. RESULTS A total of 781 eligible rivaroxaban-treated patients were propensity score-matched to 1,536 warfarin-treated patients; baseline covariates were well balanced after matching (absolute standardized differences <0.1). The average patient age was 80 years; 60.5% were female; 81.3% and 18.7% had CKD stage IV and V, respectively. Hazard ratios for rivaroxaban compared to warfarin were 0.93 (95% CI 0.46-1.90, P = .85) for the risk of ISSE and 0.91 (95% CI 0.65-1.28, P = .60) for major bleeding. CONCLUSIONS No statistically significant difference in the risk of ISSE or major bleeding was found between rivaroxaban- and warfarin-treated patients. Although further study is needed, rivaroxaban appears to be a reasonable alternative to warfarin for ISSE prevention in the setting of NVAF and stage IV-V CKD.
Collapse
|
23
|
Christensen MA, Fosbøl EL, Bonde AN, Olesen JB, Gislason GH, Torp-Pedersen C, Gundlund A. Secondary stroke prophylaxis in atrial fibrillation patients with chronic kidney disease: a nationwide cohort study. Europace 2020; 22:716-723. [PMID: 31872246 DOI: 10.1093/europace/euz340] [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: 09/02/2019] [Accepted: 12/02/2019] [Indexed: 11/12/2022] Open
Abstract
AIMS Oral anticoagulation (OAC) therapy as secondary stroke prophylaxis in atrial fibrillation (AF) patients with chronic kidney disease (CKD) remains unexplored and poses a clinical treatment dilemma. We assessed the long-term risk of thromboembolic events according to post-stroke OAC therapy in AF patients with CKD after their first ischaemic stroke. METHODS AND RESULTS We identified Danish AF patients with CKD who presented with first-time ischaemic stroke from 2005 to 2014. Chronic kidney disease was defined as a diagnosis code for CKD before baseline, defined as 100 days after stroke discharge. Post-stroke antithrombotic therapy (OAC therapy and antiplatelet therapy) was identified from prescription claims from discharge to baseline. Cumulative incidences and adjusted hazard ratios (HRs) of thromboembolic events according to post-stroke OAC therapy were examined. Of 1252 AF patients with CKD presenting with ischaemic stroke, 631 (50.4%) patients were on OAC therapy and 621 (49.6%) were on antiplatelet therapy alone at baseline [median age 76 (interquartile range, IQR 71-83) and 80 (IQR 72-86), respectively]. The median follow-up period was 1.9 years (IQR 0.8-3.6). Cumulative incidence rates of thromboembolic events and bleeding showed no significant difference between those on OAC therapy and antiplatelet therapy. The results from the multivariable analysis revealed similar results: thromboembolic risk was not modified by OAC treatment [adjusted HR 0.89, 95% confidence interval (CI) 0.73-1.09] nor was the risk of bleeding (adjusted HR 0.88, 95% CI 0.67-1.17). CONCLUSION Oral anticoagulation in patients with CKD and prior stroke was not associated with a reduced risk of recurrent thromboembolic events compared with antiplatelet therapy.
Collapse
Affiliation(s)
- Mathias Aagaard Christensen
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark.,The National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Christian Torp-Pedersen
- Department of Clinical Research and Cardiology, Nordsjællands Hospital, Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Anna Gundlund
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Hellerup, Denmark
| |
Collapse
|
24
|
Burlacu A, Genovesi S, Ortiz A, Combe C, Basile C, Schneditz D, van der Sande F, Popa GT, Morosanu C, Covic A. Pros and cons of antithrombotic therapy in end-stage kidney disease: a 2019 update. Nephrol Dial Transplant 2020; 34:923-933. [PMID: 30879070 DOI: 10.1093/ndt/gfz040] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Indexed: 12/24/2022] Open
Abstract
Dialysis patients manifest both an increased thrombotic risk and a haemorrhagic tendency. A great number of patients with chronic kidney disease requiring dialysis have cardiovascular comorbidities (coronary artery disease, atrial fibrillation or venous thromboembolism) and different indications for treatment with antithrombotics (primary or secondary prevention). Unfortunately, few randomized controlled trials deal with antiplatelet and/or anticoagulant therapy in dialysis. Therefore cardiology and nephrology guidelines offer ambiguous recommendations and often exclude or ignore these patients. In our opinion, there is a need for an expert consensus that provides physicians with useful information to make correct decisions in different situations requiring antithrombotics. Herein the European Dialysis Working Group presents up-to-date evidence about the topic and encourages practitioners to choose among alternatives in order to limit bleeding and minimize atherothrombotic and cardioembolic risks. In the absence of clear evidence, these clinical settings and consequent therapeutic strategies will be discussed by highlighting data from observational studies for and against the use of antiplatelet and anticoagulant drugs alone or in combination. Until new studies shed light on unclear clinical situations, one should keep in mind that the objective of treatment is to minimize thrombotic risk while reducing bleeding events.
Collapse
Affiliation(s)
- Alexandru Burlacu
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, San Gerardo Hospital, University of Milan Bicocca Nephrology Unit, Monza, Italy
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz UAM, FRIAT and REDINREN, Madrid, Spain
| | - Christian Combe
- Service de Néphrologie Transplantation Dialyse Aphérèse, Centre Hospitalier Universitaire de Bordeaux, Unité INSERM 1026, Université de Bordeaux, Bordeaux, France
| | - Carlo Basile
- Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
| | - Daniel Schneditz
- Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Frank van der Sande
- Department of Internal Medicine, Division of Nephrology, University Hospital Maastricht, Maastricht, The Netherlands
| | - Grigore T Popa
- Department of General Surgery, Regional Institute of Oncology, University of Medicine, Iasi, Romania
| | - Cornel Morosanu
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. Parhon' University Hospital, 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | | |
Collapse
|
25
|
Xipell M, Flores-Umanzor E, Ojeda R, Arias M, Cepas-Guillén PL, Regueiro A, Freixa X, Cases A, Maduell F. Percutaneous left atrial appendage closure, a safe alternative to anticoagulation for patients with nonvalvular atrial fibrillation and end-stage renal disease on hemodialysis: A single center experience. Artif Organs 2019; 44:513-521. [PMID: 31715006 DOI: 10.1111/aor.13603] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 10/14/2019] [Accepted: 11/08/2019] [Indexed: 12/11/2022]
Abstract
The evidence about the effectiveness and safety of oral anticoagulation in patients on hemodialysis is conflicting and scarce. Percutaneous left atrial appendage occlusion (LAAO) has demonstrated to be a valid alternative therapeutic option for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). The aim of this study is to present the outcomes of percutaneous LAAO in patients with end-stage renal disease (ESRD) on hemodialysis and NVAF in our center. We conducted a retrospective review of clinical records, demographics, LAAO procedure, complications, and outcomes of patients with NVAF and ESRD on hemodialysis who underwent a percutaneous LAAO in our center between January 2017 and January 2019. In the period of the study, eight patients with ESRD on hemodialysis underwent a percutaneous LAAO in our center. The overall mean age was 67.5 years (range 56-81; SD ± 7.2). All patients had permanent NVAF. The total mean dialysis duration was 8.49 years (range 0.83-14.8; SD ± 6.2). The mean CHA2DS2-VASc and HAS-BLED scores were high (4.75 [SD ± 1.16] and 4.62 [SD ± 0.91], respectively). All patients had history of a major hemorrhagic event (BARC Score ≥3). Most patients (n = 6) showed left ventricular hypertrophy, and the average LVEF was 54% (SD ± 6.5). All devices were implanted successfully. Postprocedural antithrombotic regimen prescribed was based on antiplatelet therapy. No deaths, cardioembolic events, or major bleeding (according to the BARC scale) were reported during a mean follow-up of 14.24 months (SD ± 9.44). Percutaneous LAAO could be of particular interest in patients with NVAF and CKD in hemodialysis. Further studies will be necessary to confirm this hypothesis.
Collapse
Affiliation(s)
- Marc Xipell
- Nephrology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Raquel Ojeda
- Nephrology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Marta Arias
- Nephrology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Ander Regueiro
- Cardiology Department, Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Xavier Freixa
- Cardiology Department, Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Aleix Cases
- Nephrology Department, Hospital Clínic de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain
| | - Francisco Maduell
- Nephrology Department, Hospital Clínic de Barcelona, Barcelona, Spain.,Universitat de Barcelona, Barcelona, Spain
| |
Collapse
|
26
|
Song T, Yin S, Jiang Y, Huang Z, Liu J, Wang Z, Li L, Zeng J, Fan Y, Wang X, Li X, Lin T. Increasing Time in Therapeutic Range of Tacrolimus in the First Year Predicts Better Outcomes in Living-Donor Kidney Transplantation. Front Immunol 2019; 10:2912. [PMID: 31921171 PMCID: PMC6933438 DOI: 10.3389/fimmu.2019.02912] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 11/27/2019] [Indexed: 02/05/2023] Open
Abstract
Background: The aim of the present study was to investigate the impact of time in therapeutic range TTR on long-term outcomes of living kidney transplants. Methods: We included 1,241 living kidney transplants and randomized them into development and validation cohorts with a ratio of 2:1. The tacrolimus TTR percentage was calculated by linear interpolation with a target range (5–10 ng/ml months 0–3, 4–8 ng/ml months 4–12). The optimal TTR cutoff was estimated by the receiver operating characteristic curve analysis on the basis of acute rejection (AR) within 12 months in the development cohort. Outcomes were analyzed between patients with high TTR and low TTR in the development and validation cohorts, respectively. The TTR was also compared with other tacrolimus measures. Results: The optimal TTR cutoff value was 78%. In the development cohort, patients with TTR > 78% had significantly higher rejection- and infection-free survival. TTR < 78% was an independent risk factor for AR (OR: 2.97, 95%CI: 1.82–4.84) and infection (OR: 1.55, 95%CI: 1.08–2.22). Patient and graft survival were significantly higher in those with TTR>78%, and TTR<78% was associated with graft loss (OR: 3.2, 95%CI: 1.38–7.42) and patient death (OR: 6.54, 95%CI: 1.34–31.77). These findings were confirmed in the validation cohort. Furthermore, we divided all included patients into a high and low TTR group. TTR was more strongly associated with patient and graft survival than mean level, standard deviation, and intrapatient variability (IPV). Conclusions: Increasing the TTR of tacrolimus in the first year was associated with improved long-term outcomes in living kidney transplants, and TTR may be a novel valuable strategy to monitor tacrolimus exposure.
Collapse
Affiliation(s)
- Turun Song
- Urology Department, Urology Research Institute, Organ Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Saifu Yin
- Urology Department, Urology Research Institute, Organ Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Yamei Jiang
- Urology Department, Urology Research Institute, Organ Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Zhongli Huang
- Urology Department, Urology Research Institute, Organ Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Jinpeng Liu
- Urology Department, Urology Research Institute, Organ Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiling Wang
- Urology Department, Urology Research Institute, Organ Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Linde Li
- Urology Department, Urology Research Institute, Organ Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Zeng
- Urology Department, Urology Research Institute, Organ Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Fan
- Urology Department, Urology Research Institute, Organ Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Xianding Wang
- Urology Department, Urology Research Institute, Organ Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Xingxing Li
- Urology Department, Urology Research Institute, Organ Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Lin
- Urology Department, Urology Research Institute, Organ Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
27
|
Abstract
Supplemental Digital Content is available in the text. The Time in Therapeutic Range (TTR) is the gold-standard measure used to assess the quality of oral anticoagulation with vitamin K antagonists. However, TTR is a static measure, and International Normalized Ratio (INR) control is a dynamic process. Group-based Trajectory Models (GBTM) can address this dynamic nature by classifying patients into different trajectories of INR control over time.
Collapse
|
28
|
Cao Y, Chen G, Li H, Liu Y, Tao Z, Li L, Chen W, Xu Y, Chen X. De Ritis ratio as a significant prognostic factor of international normalized ratio ≥4 in the initial 10 days of warfarin therapy. Biomark Med 2019; 13:1599-1607. [PMID: 31660758 DOI: 10.2217/bmm-2019-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To assess the relationship between the De Ritis ratio on admission and warfarin sensitivity in the initial 10 days of anticoagulation therapy. Methods: We retrospectively reviewed data from 906 patients who underwent heart valve replacement surgery. Results: A De Ritis ratio of 1.19 was identified as the optimal cutoff according to the ROC curve. Patients with a high De Ritis ratio achieved an international normalized ratio (INR) ≥4 more easily and earlier than those with a low De Ritis ratio in the initial 10 days of warfarin therapy. Multivariate analysis showed that a high De Ritis ratio was an independent predictor of an INR ≥4 (HR: 2.567; p < 0.001). Conclusion: A De Ritis ratio ≥1.19 on admission was significantly associated with an INR ≥4 in the initial 10 days of warfarin therapy among patients underwent heart valve replacement surgery.
Collapse
Affiliation(s)
- Yide Cao
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, PR China
| | - Ganyi Chen
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, PR China
| | - Huangshu Li
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, PR China
| | - Yafeng Liu
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, PR China
| | - Zhonghao Tao
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, PR China
| | - Liangpeng Li
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, PR China
| | - Wen Chen
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, PR China
| | - Yueyue Xu
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, PR China
| | - Xin Chen
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Changle Road 68, Nanjing, Jiangsu, PR China
| |
Collapse
|
29
|
Komen JJ, Forslund T, Mantel-Teeuwisse AK, Klungel OH, von Euler M, Braunschweig F, Wallén H, Hjemdahl P. Association of preceding antithrombotic therapy in atrial fibrillation patients with ischaemic stroke, intracranial haemorrhage, or gastrointestinal bleed and mortality. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 7:3-10. [PMID: 31665368 PMCID: PMC7811399 DOI: 10.1093/ehjcvp/pvz063] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 09/18/2019] [Accepted: 10/24/2019] [Indexed: 11/21/2022]
Abstract
Aims To analyse 90-day mortality in atrial fibrillation (AF) patients after a stroke or a severe bleed and assess associations with the type of antithrombotic treatment at the event. Methods and results From the Stockholm Healthcare database, we selected 6017 patients with a known history of AF who were diagnosed with ischaemic stroke, 3006 with intracranial haemorrhage, and 4291 with a severe gastrointestinal bleed (GIB). The 90-day mortality rates were 25.1% after ischaemic stroke, 31.6% after intracranial haemorrhage, and 16.2% after severe GIB. We used Cox regression and propensity score-matched analyses to test the association between antithrombotic treatment at the event and 90-day mortality. After intracranial haemorrhage, there was a significantly higher mortality rate in warfarin compared to non-vitamin K oral anticoagulant (NOAC)-treated patients [adjusted hazard ratio (aHR) 1.36, 95% confidence interval (CI) 1.04–1.78]. After an ischaemic stroke and a severe GIB, patients receiving antiplatelets or no antithrombotic treatment had significantly higher mortality rates compared to patients on NOACs, but there was no difference comparing warfarin to NOACs (aHR 0.84, CI 0.63–1.12 after ischaemic stroke, aHR 0.91, CI 0.66–1.25 after severe GIB). Propensity score-matched analysis yielded similar results. Conclusion Mortality rates were high in AF patients suffering from an ischaemic stroke, an intracranial haemorrhage, or a severe GIB. NOAC treatment was associated with a lower 90-day mortality after intracranial haemorrhage than warfarin.
Collapse
Affiliation(s)
- Joris J Komen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands.,Stockholm County Council, Department of Healthcare Development, Sweden
| | - Tomas Forslund
- Stockholm County Council, Department of Healthcare Development, Sweden.,Department of Medicine Solna, Clinical Epidemiology Unit/Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, the Netherlands
| | - Mia von Euler
- Department of Medicine Solna, Clinical Epidemiology Unit/Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science and Education, Karolinska Institutet Stroke Research Network at Södersjukhuset, Stockholm, Sweden
| | - Frieder Braunschweig
- Department of Medicine Solna, Cardiology Unit, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Paul Hjemdahl
- Department of Medicine Solna, Clinical Epidemiology Unit/Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
30
|
Mertens C, Siebenhofer A, Berghold A, Pregartner G, Ulrich LR, Mergenthal K, Kemperdick B, Schulz-Rothe S, Rauck S, Harder S, Gerlach FM, Petersen JJ. Differences in the quality of oral anticoagulation therapy with vitamin K antagonists in German GP practices - results of the cluster-randomized PICANT trial (Primary Care Management for Optimized Antithrombotic Treatment). BMC Health Serv Res 2019; 19:539. [PMID: 31370840 PMCID: PMC6676561 DOI: 10.1186/s12913-019-4372-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/25/2019] [Indexed: 12/15/2022] Open
Abstract
Background In Germany, patients receiving oral anticoagulation (OAC) are often treated by general practitioners (GPs), and large proportions of patients receive vitamin K antagonists (VKAs). The quality of OAC in German GP practices, differences between various practices, and improvement potential through implementation of case management, have not yet been investigated satisfactorily. Based on results of a cluster-randomized controlled trial, we aimed to assess whether OAC quality can be improved, any variations between practices exist and determine practice- and patient-level factors. Methods The PICANT trial (2012–2015) was performed in 52 GP practices in Hesse, Germany. Adult patients with long-term indication for OAC received best practice case management in the intervention group. International normalized ratio (INR) values were recorded from anticoagulation passes. The Rosendaal method was used to calculate Time in Therapeutic Range (TTR) at patient level, and mean pooling to obtain center-specific TTR (cTTR) at practice level. The quality of OAC was assessed by TTR and cTTR. Linear model analyses were used to investigate associations between practice−/ patient-level factors and TTR. Results Inclusion of 736 patients (49.6% intervention and 50.4% control patients); 690 (93.8%) received phenprocoumon. Within 24 months, the TTR was 75.1% (SD 17.6) in the intervention versus 74.3% (SD 17.8) in the control group (p = 0.670). The cTTR averaged 75.1% (SD 6.5, range: 60.4 to 86.7%) in the intervention versus 74.3% (SD 7.2, range: 52.7 to 85.7%) in the control group (p = 0.668). At practice level, the TTR was significantly lower in practices with a male physician and certification in quality management. At patient level, the TTR was significantly higher in patients with moderate to high compliance, in men, and in patients that performed self-management. The TTR was significantly lower in patients with certain comorbidities, and who were hospitalized. Conclusions The intervention did not effectively improve OAC quality compared to routine care. Quality of INR control was generally good, but considerable variation existed between GP practices. The variability indicates optimization potential in some practices. The demonstrated association between patient-level factors and TTR highlights the importance of considering patient characteristics that may impede achieving high quality therapeutic outcomes. Trial registration ISRCTN registry, ISRCTN41847489, registered 27 February 2012. Electronic supplementary material The online version of this article (10.1186/s12913-019-4372-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Cornelia Mertens
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Andrea Siebenhofer
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany. .,Institute of General Practice and Evidence-based Health Services Research, Medical University Graz, Auenbruggerplatz 2/9, A-8036, Graz, Austria.
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University Graz, Auenbruggerplatz 2/9, A-8036, Graz, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and Documentation, Medical University Graz, Auenbruggerplatz 2/9, A-8036, Graz, Austria
| | - Lisa-Rebekka Ulrich
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Karola Mergenthal
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Birgit Kemperdick
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Sylvia Schulz-Rothe
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Sandra Rauck
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Sebastian Harder
- Institute of Clinical Pharmacology, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Ferdinand Michael Gerlach
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Juliana Johanna Petersen
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| |
Collapse
|
31
|
Atrial fibrillation and chronic kidney disease conundrum: an update. J Nephrol 2019; 32:909-917. [DOI: 10.1007/s40620-019-00630-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/10/2019] [Indexed: 12/15/2022]
|
32
|
Sambola A, Bueno H, Gordon B, Mutuberría M, Barrabés JA, Del Blanco BG, González-Fernández V, Casamira N, García-Dorado D. Worse 12-month prognosis in women with non-valvular atrial fibrillation undergoing percutaneous coronary intervention. Thromb Res 2019; 178:20-25. [DOI: 10.1016/j.thromres.2019.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/13/2019] [Accepted: 03/27/2019] [Indexed: 10/27/2022]
|
33
|
Rohla M, Weiss TW, Pecen L, Patti G, Siller-Matula JM, Schnabel RB, Schilling R, Kotecha D, Lucerna M, Huber K, De Caterina R, Kirchhof P. Risk factors for thromboembolic and bleeding events in anticoagulated patients with atrial fibrillation: the prospective, multicentre observational PREvention oF thromboembolic events - European Registry in Atrial Fibrillation (PREFER in AF). BMJ Open 2019; 9:e022478. [PMID: 30928922 PMCID: PMC6475354 DOI: 10.1136/bmjopen-2018-022478] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES We identified factors associated with thromboembolic and bleeding events in two contemporary cohorts of anticoagulated patients with atrial fibrillation (AF), treated with either vitamin K antagonists (VKA) or non-VKA oral anticoagulants (NOACs). DESIGN Prospective, multicentre observational study. SETTING 461 centres in seven European countries. PARTICIPANTS 5310 patients receiving a VKA (PREvention oF thromboembolic events - European Registry in Atrial Fibrillation (PREFER in AF), derivation cohort) and 3156 patients receiving a NOAC (PREFER in AF Prolongation, validation cohort) for stroke prevention in AF. OUTCOME MEASURES Risk factors for thromboembolic events (ischaemic stroke, systemic embolism) and major bleeding (gastrointestinal bleeding, intracerebral haemorrhage and other life-threatening bleeding). RESULTS The mean age of patients enrolled in the PREFER in AF registry was 72±10 years, 40% were female and the mean CHA2DS2-VASc Score was 3.5±1.7. The incidence of thromboembolic and major bleeding events was 2.34% (95% CI 1.93% to 2.74%) and 2.84% (95% CI 2.41% to 3.33%) after 1-year of follow-up, respectively.Abnormal liver function, prior stroke or transient ischaemic attack, labile international normalised ratio (INR), concomitant therapy with antiplatelet or non-steroidal anti-inflammatory drugs, heart failure and older age (≥75 years) were independently associated with both thromboembolic and major bleeding events.With the exception of unstable INR values, these risk factors were validated in patients treated with NOACs (PREFER in AF Prolongation Study, 72±9 years, 40% female, CHA2DS2-VASc 3.3±1.6). For each single point decrease on a modifiable bleeding risk scale we observed a 30% lower risk for major bleeding events (OR 0.70, 95% CI 0.64 to 0.76, p<0.01) and a 28% lower rate of thromboembolic events (OR 0.72, 95% CI 0.66 to 0.82, p<0.01). CONCLUSION Attending to modifiable risk factors is an important treatment target in anticoagulated AF patients to reduce thromboembolic and bleeding events. Initiation of anticoagulation in those at risk of stroke should not be prevented by elevated bleeding risk scores.
Collapse
Affiliation(s)
- Miklos Rohla
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
- Institute for Cardiometabolic Diseases, Karl Landsteiner Society, St. Pölten, Austria
| | - Thomas W Weiss
- Institute for Cardiometabolic Diseases, Karl Landsteiner Society, St. Pölten, Austria
- Cardiology, Sigmund Freud University, Medical School, Vienna, Austria
| | - Ladislav Pecen
- Cardiology, Medical Faculty Pilsen, Charles University, Pilsen, Czech Republic
| | - Giuseppe Patti
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Renate B Schnabel
- University Heart Center Hamburg, Clinic for General and Interventional Cardiology, Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | | | - Dipak Kotecha
- University of Birmingham Institute of Cardiovascular Sciences, University of Birmingham, UHB and SWBH NHS Trusts, Birmingham, UK
| | | | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
- Cardiology, Sigmund Freud University, Medical School, Vienna, Austria
| | - Raffaele De Caterina
- University of Pisa and Division of Cardiology, Pisa University Hospital, Pisa, Italy
| | - Paulus Kirchhof
- University of Birmingham Institute of Cardiovascular Sciences, University of Birmingham, UHB and SWBH NHS Trusts, Birmingham, UK
| |
Collapse
|
34
|
Goto S, Angchaisuksiri P, Bassand J, Camm AJ, Dominguez H, Illingworth L, Gibbs H, Goldhaber SZ, Goto S, Jing Z, Haas S, Kayani G, Koretsune Y, Lim TW, Oh S, Sawhney JPS, Turpie AGG, van Eickels M, Verheugt FWA, Kakkar AK. Management and 1-Year Outcomes of Patients With Newly Diagnosed Atrial Fibrillation and Chronic Kidney Disease: Results From the Prospective GARFIELD - AF Registry. J Am Heart Assoc 2019; 8:e010510. [PMID: 30717616 PMCID: PMC6405596 DOI: 10.1161/jaha.118.010510] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 12/24/2018] [Indexed: 01/11/2023]
Abstract
Background Using data from the GARFIELD - AF (Global Anticoagulant Registry in the FIELD -Atrial Fibrillation), we evaluated the impact of chronic kidney disease ( CKD ) stage on clinical outcomes in patients with newly diagnosed atrial fibrillation ( AF ). Methods and Results GARFIELD - AF is a prospective registry of patients from 35 countries, including patients from Asia (China, India, Japan, Singapore, South Korea, and Thailand). Consecutive patients enrolled (2013-2016) were classified with no, mild, or moderate-to-severe CKD , based on the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative guidelines. Data on CKD status and outcomes were available for 33 024 of 34 854 patients (including 9491 patients from Asia); 10.9% (n=3613) had moderate-to-severe CKD , 16.9% (n=5595) mild CKD , and 72.1% (n=23 816) no CKD . The use of oral anticoagulants was influenced by stroke risk (ie, post hoc assessment of CHA 2 DS 2- VAS c score), but not by CKD stage. The quality of anticoagulant control with vitamin K antagonists did not differ with CKD stage. After adjusting for baseline characteristics and antithrombotic use, both mild and moderate-to-severe CKD were independent risk factors for all-cause mortality. Moderate-to-severe CKD was independently associated with a higher risk of stroke/systemic embolism, major bleeding, new-onset acute coronary syndrome, and new or worsening heart failure. The impact of moderate-to-severe CKD on mortality was significantly greater in patients from Asia than the rest of the world ( P=0.001). Conclusions In GARFIELD - AF , moderate-to-severe CKD was independently associated with stroke/systemic embolism, major bleeding, and mortality. The effect of moderate-to-severe CKD on mortality was even greater in patients from Asia than the rest of the world. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01090362.
Collapse
Affiliation(s)
- Shinya Goto
- Tokai University School of MedicineKanagawaJapan
| | | | - Jean‐Pierre Bassand
- University of BesançonFrance
- Thrombosis Research InstituteLondonUnited Kingdom
| | - A. John Camm
- St. George's University of LondonLondonUnited Kingdom
| | - Helena Dominguez
- Bispebjerg‐Frederiksberg HospitalCopenhagenDenmark
- Faculty of Health SciencesUniversity of CopenhagenCopenhagenDenmark
| | | | | | | | | | - Zhi‐Cheng Jing
- Fu Wai HospitalState Key Lab of Cardiovascular DiseaseNational Center for Cardiovascular DiseasePUMC & CAMSBeijingChina
| | - Sylvia Haas
- Formerly Klinikum rechts der IsarTechnical University of MunichGermany
| | | | | | | | - Seil Oh
- Seoul National University HospitalSeoulKorea
| | | | | | | | | | - Ajay K. Kakkar
- Thrombosis Research InstituteLondonUnited Kingdom
- University College LondonLondonUnited Kingdom
| |
Collapse
|
35
|
Massicotte-Azarniouch D, Sood MM. Uncertainty surrounds anticoagulation risks and benefits in patients with chronic kidney disease with atrial fibrillation. BMJ Evid Based Med 2019; 24:35-36. [PMID: 30006370 DOI: 10.1136/bmjebm-2018-110992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2018] [Indexed: 11/04/2022]
Affiliation(s)
| | - Manish M Sood
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| |
Collapse
|
36
|
Abohelaika S, Wynne H, Avery P, Robinson B, Jones L, Tait C, Dickinson B, Salisbury J, Nightingale J, Green L, Kamali F. Individual and monitoring centre influences upon anticoagulation control of AF patients on warfarin: A longitudinal multi-centre UK-based study. Eur J Haematol 2018; 101:486-495. [PMID: 29949204 DOI: 10.1111/ejh.13130] [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: 05/17/2018] [Accepted: 06/24/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Time within therapeutic INR range (TTR) predicts benefits/risk of warfarin therapy. Identification of individual- and centre-related factors that influence TTR, and addressing them to improve anticoagulation control, are important. This study examined the impact of individual and centre-related factors upon long-term anticoagulation control in atrial fibrillation patients in seven UK-based monitoring services. METHODS Data between 2000 and 2014 on 25 270 patients (equating to 203 220 patient years) [18 120 (71.7%) in general practice, 2348 (9.3%) in hospital-based clinics and 4802 (19.0%) in domiciliary service] were analysed. RESULTS TTR increased with increasing age, peaking around 77% at 70-75 years, and then declined, was lower in females than males, and in dependent home-monitored patients than those attending clinic (P < 0.0001). TTR, number of dose changes and INR monitoring events and the probability of TTR ≤ 65%, differed across the centres (P < 0.0001). CONCLUSIONS Although all the participating centres ostensively followed a standard dosing algorithm, our results indicate that variations in practice do occur between different monitoring sites. We suggest feedback on TTR for individual monitoring sites gauged against the average values reported by others would empower the individual centres to improve quality outcomes of anticoagulation therapy by identifying and adjusting contributory factors within their management system.
Collapse
Affiliation(s)
- Salah Abohelaika
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Hilary Wynne
- Older People's Medicine, Newcastle upon Tyne Hospitals, NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Peter Avery
- School of Mathematics and Statistics, Newcastle University, Newcastle upon Tyne, UK
| | - Brian Robinson
- Department of Haematology, Newcastle upon Tyne Hospitals, NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Lisa Jones
- Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Campbell Tait
- NHS Greater Glasgow and Clyde Anticoagulation Service, Glasgow, UK
| | | | | | | | - Louise Green
- Royal Shrewsbury Hospital Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Farhad Kamali
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
37
|
Inoue H, Kodani E, Atarashi H, Okumura K, Yamashita T, Origasa H. Renal Dysfunction Affects Anticoagulation Control With Warfarin and Outcomes in Japanese Elderly Patients With Non-Valvular Atrial Fibrillation. Circ J 2018; 82:2277-2283. [PMID: 29984788 DOI: 10.1253/circj.cj-18-0242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND It is unclear whether renal dysfunction affects warfarin control in patients with non-valvular atrial fibrillation (NVAF). Methods and Results: Using a dataset from the J-RHYTHM Registry, time in therapeutic range (TTR) of the international normalized ratio (INR) of prothrombin time, and creatinine clearance (CrCl) were determined in elderly patients aged ≥70 years. Target INR values were 1.6-2.6 following Japanese guidelines. Incidences of thromboembolism, major hemorrhage, and all-cause death were determined over 2 years. Of 7,406 NVAF patients enrolled in the registry, 2,782 elderly patients (mean age, 75 years) had data for CrCl measured at baseline and TTR. TTR values were lower in the lower CrCl groups (P<0.001 for trend). CrCl <30 mL/min was independently associated with TTR <65% (odds ratio, 1.49; 95% confidence interval, 1.13-1.95; P=0.004). In the multivariate analysis, TTR <65% was independently associated with thromboembolism (hazard ratio, 2.26; 95% confidence interval, 1.37-3.72; P=0.001), but CrCl was not (CrCl <30 mL/min, 1.68, 0.41-6.85, P=0.473). However, CrCl <30 mL/min and TTR <65% were independently associated with all-cause death (5.32, 1.56-18.18, P=0.008 and 1.60, 1.07-2.38, P=0.022, respectively) and the composite event (thromboembolism, major hemorrhage and all-cause death) (2.03, 1.10-3.76, P=0.024 and 1.58, 1.22-2.04, P=0.001, respectively). CONCLUSIONS Elderly NVAF patients with renal dysfunction had poor warfarin control, which was associated with higher risk of thromboembolism and all-cause death.
Collapse
Affiliation(s)
| | - Eitaro Kodani
- Department of Internal Medicine, Nippon Medical School Tama-Nagayama Hospital
| | - Hirotsugu Atarashi
- Department of Internal Medicine, Nippon Medical School Tama-Nagayama Hospital
| | - Ken Okumura
- Department of Cardiology, Saiseikai Kumamoto Hospital
| | | | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Graduate School of Medicine
| | | |
Collapse
|
38
|
Implant success and safety of left atrial appendage occlusion in end stage renal disease patients: Peri-procedural outcomes from an Italian dialysis population. Int J Cardiol 2018; 262:38-42. [DOI: 10.1016/j.ijcard.2018.03.083] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 03/09/2018] [Accepted: 03/16/2018] [Indexed: 11/19/2022]
|
39
|
Turakhia MP, Blankestijn PJ, Carrero JJ, Clase CM, Deo R, Herzog CA, Kasner SE, Passman RS, Pecoits-Filho R, Reinecke H, Shroff GR, Zareba W, Cheung M, Wheeler DC, Winkelmayer WC, Wanner C. Chronic kidney disease and arrhythmias: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Eur Heart J 2018; 39:2314-2325. [PMID: 29522134 PMCID: PMC6012907 DOI: 10.1093/eurheartj/ehy060] [Citation(s) in RCA: 167] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/18/2017] [Accepted: 01/27/2018] [Indexed: 12/15/2022] Open
MESH Headings
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/therapy
- Atrial Fibrillation/complications
- Atrial Fibrillation/drug therapy
- Atrial Fibrillation/epidemiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Humans
- Hyperkalemia/epidemiology
- Hyperkalemia/metabolism
- Hypokalemia/epidemiology
- Hypokalemia/metabolism
- Inflammation
- Kidney Failure, Chronic/epidemiology
- Kidney Failure, Chronic/metabolism
- Kidney Failure, Chronic/therapy
- Oxidative Stress
- Potassium/metabolism
- Renal Dialysis
- Renal Insufficiency, Chronic/epidemiology
- Renal Insufficiency, Chronic/metabolism
- Renal Insufficiency, Chronic/therapy
- Risk Factors
- Stroke/etiology
- Stroke/prevention & control
Collapse
Affiliation(s)
- Mintu P Turakhia
- Stanford University School of Medicine, Veterans Affairs Palo Alto Health Care System, Miranda Ave, Palo Alto, CA, USA
| | - Peter J Blankestijn
- Department of Nephrology, room F03.220, University Medical Center, Utrecht, The Netherlands
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, St. Joseph’s Healthcare, Marian Wing, 3rd Floor, M333, 50 Charlton Ave. E, Hamilton, Ontario, Canada
| | - Rajat Deo
- Section of Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, 9 Founders Cardiology, Philadelphia, PA, USA
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota and Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 S. 8th Street, S4.100, Minneapolis, MN, USA
| | - Scott E Kasner
- Department of Neurology, 3W Gates Bldg. Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, USA
| | - Rod S Passman
- Northwestern University Feinberg School of Medicine and the Bluhm Cardiovascular Institute, 201 E. Huron St. Chicago, IL, USA
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Rua Imaculada Conceição Curitiba PR, Brazil
| | - Holger Reinecke
- Department für Kardiologie und Angiologie Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Muenster, Germany
| | - Gautam R Shroff
- Division of Cardiology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, USA
| | - Wojciech Zareba
- Heart Research Follow-up Program, Cardiology Division, University of Rochester Medical Center, Saunders Research Building, 265 Crittenden Blvd. CU, Rochester, NY, USA
| | | | - David C Wheeler
- Centre for Nephrology, University College London, Rowland Hill Street, London, UK
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, ABBR R705, MS: 395, Houston, TX, USA
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Oberduerrbacherstr. 6 Würzburg, Germany
| |
Collapse
|
40
|
Uso de anticoagulantes orales en situaciones clínicas complejas con fibrilación auricular. Med Clin (Barc) 2018; 150 Suppl 1:8-24. [DOI: 10.1016/s0025-7753(18)30666-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
41
|
Bleeding events attributable to concurrent use of warfarin and other medications in high-risk elderly: meta-analysis and Italian population-based investigation. Eur J Clin Pharmacol 2018; 74:1061-1070. [DOI: 10.1007/s00228-018-2467-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/23/2018] [Indexed: 02/01/2023]
|
42
|
Sánchez Soriano RM, Albero Molina MD, Chamorro Fernández CI, Juliá-Sanchís R, López Menchero R, Del Pozo Fernández C, Grau Jornet G, Núñez Villota J. Long-term prognostic impact of anticoagulation on patients with atrial fibrillation undergoing hemodialysis. Nefrologia 2018; 38:394-400. [PMID: 29426785 DOI: 10.1016/j.nefro.2017.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 08/16/2017] [Accepted: 11/28/2017] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Evidence for the efficacy and safety of oral anticoagulation with dicumarines in patients with atrial fibrillation (AF) on hemodialysis is controversial. The aim of our study is to evaluate the long-term prognostic implications of anticoagulation with dicumarines in a cohort of patients with non-valvular AF on a hemodialysis program due to end-stage renal disease. METHODS Retrospective, observational study with consecutive inclusion of 74 patients with AF on hemodialysis. The inclusion period was from January 2005 to October 2016. The primary variables were all-cause mortality, non-scheduled readmissions and bleeding during follow-up. RESULTS Mean age was 75±10 years; 66.2% were men and 43 patients (58.1%) received acenocoumarol. During a median follow-up of 2.40 years (IQR=0.88-4.15), acenocoumarol showed no survival benefit [HR=0.76, 95% CI (0.35-1.66), p=0.494]. However, anticoagulated patients were at increased risk of recurrent cardiovascular hospitalizations [IRR=3.94, 95% CI (1.06-14.69), p=0.041]. There was a trend towards an increase in repeated hospitalizations of ischemic cause in anticoagulated patients [IRR=5.80, 95% CI (0.86-39.0), p=0.071]. There was a statistical trend towards a higher risk of recurrent total bleeding in patients treated with acenocoumarol [IRR=4.43, 95% CI (0.94-20.81), p=0.059]. CONCLUSIONS In this study, oral anticoagulation with acenocoumarol in patients with AF on hemodialysis did not increase survival. However, it was associated with an increased risk of hospitalizations of cardiovascular causes and a tendency to an increased risk of total bleeding.
Collapse
Affiliation(s)
| | | | | | - Rocío Juliá-Sanchís
- Universidad de Alicante, Facultad Ciencias de La Salud (Enfermería), Alicante, España
| | | | | | | | - Julio Núñez Villota
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de València. CIBER Cardiovascular , Valencia, España
| |
Collapse
|
43
|
Bilha SC, Burlacu A, Siriopol D, Voroneanu L, Covic A. Primary Prevention of Stroke in Chronic Kidney Disease Patients: A Scientific Update. Cerebrovasc Dis 2018; 45:33-41. [PMID: 29316564 DOI: 10.1159/000486016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 12/02/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Although chronic kidney disease (CKD) is an independent risk factor for stroke, official recommendations for the primary prevention of stroke in CKD are generally lacking. SUMMARY We searched PubMed and ISI Web of Science for randomised controlled trials, observational studies, reviews, meta-analyses and guidelines referring to measures of stroke prevention or to the treatment of stroke-associated risk factors (cardiovascular disease in general and atrial fibrillation (AF), arterial hypertension or carotid artery disease in particular) among the CKD population. The use of oral anticoagulation in AF appears safe in non-end stage CKD, but it should be individualized and preferably based on thromboembolic and bleeding stratification algorithms. Non-vitamin K antagonist oral anticoagulants with definite dose adjustment are generally preferred over vitamin K antagonists in mild and moderate CKD and their indications have started being extended to severe CKD and dialysis also. Aspirin, but not clopidogrel, has limited indications for reducing the risk for atherothrombotic events in CKD due to its increased bleeding risk. Carotid endarterectomy has shown promising results for stroke risk reduction in CKD patients with high-grade symptomatic carotid stenosis. The medical treatment of arterial hypertension in CKD often fails to efficiently lower blood pressure values, but recent data regarding the use of interventional procedures such as renal denervation, baroreflex activation therapy or renal artery stenting are encouraging. Key Messages: In the absence of clear guidelines and protocols, primary prevention of stroke in CKD patients remains a subtle art in the hands of the clinicians. Nevertheless, refraining CKD patients from standard therapies often worsens their prognosis.
Collapse
Affiliation(s)
- Stefana Catalina Bilha
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Alexandru Burlacu
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
| | - Dimitrie Siriopol
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Nephrology Clinic, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, Iasi, Romania
| | - Luminita Voroneanu
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Nephrology Clinic, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, Iasi, Romania
| | - Adrian Covic
- Department of Nephrology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Nephrology Clinic, Dialysis and Renal Transplant Center, "C.I. Parhon" University Hospital, Iasi, Romania
| |
Collapse
|
44
|
Aachi RV, Birnbaum LA, Topel CH, Seifi A, Hafeez S, Behrouz R. Laboratory characteristics of ischemic stroke patients with atrial fibrillation on or off therapeutic warfarin. Clin Cardiol 2017; 40:1347-1351. [PMID: 29251360 DOI: 10.1002/clc.22838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/15/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In patients with atrial fibrillation (AF), despite adequate anticoagulation, ischemic stroke (IS) is an uncommon yet concerning occurrence. HYPOTHESIS Specific laboratory parameters may affect the efficacy of warfarin despite therapeutic international normalized ratio (INR) in patient with AF who present with IS. METHODS We used the database from a multicenter clinical trial to identify AF patients who presented with IS. We trichotomized the cohort into patients with therapeutic INR on warfarin, subtherapeutic INR on warfarin, and on no anticoagulants. We then compared baseline laboratory characteristics and other baseline features among the groups. RESULTS Patients with therapeutic INR presented with higher serum creatinine (P = 0.01) and blood urea nitrogen (P = 0.02) and lower glomerular filtration rates (P = 0.001) compared with other groups. Other laboratory parameters were not different among the 3 groups. Patients with therapeutic INR also presented with milder stroke symptoms (P = 0.01). Medical history of the 3 groups was not different, except for history of valvular heart disease, which was more prevalent in patients with therapeutic INR (P = 0.004). In-hospital mortality rates and 90-day disability were not different among the 3 groups. CONCLUSIONS AF patients who presented with IS on therapeutic warfarin had higher average serum creatinine and blood urea nitrogen, and lower glomerular filtration rates, compared with others. Impaired renal function may be a factor contributing to occurrence of IS in AF patients despite adequate anticoagulation. Larger, targeted studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Raghav V Aachi
- Department of Neurology, University of Texas Lozano Long School of Medicine, San Antonio
| | - Lee A Birnbaum
- Department of Neurology, University of Texas Lozano Long School of Medicine, San Antonio.,Department of Neurological Surgery, University of Texas Lozano Long School of Medicine, San Antonio
| | - Christopher H Topel
- Department of Neurology, University of Texas Lozano Long School of Medicine, San Antonio
| | - Ali Seifi
- Department of Neurological Surgery, University of Texas Lozano Long School of Medicine, San Antonio
| | - Shaheryar Hafeez
- Department of Neurological Surgery, University of Texas Lozano Long School of Medicine, San Antonio
| | - Réza Behrouz
- Department of Neurology, University of Texas Lozano Long School of Medicine, San Antonio
| |
Collapse
|
45
|
Sciascia S, Radin M, Schreiber K, Fenoglio R, Baldovino S, Roccatello D. Chronic kidney disease and anticoagulation: from vitamin K antagonists and heparins to direct oral anticoagulant agents. Intern Emerg Med 2017; 12:1101-1108. [PMID: 28929298 DOI: 10.1007/s11739-017-1753-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/11/2017] [Indexed: 01/18/2023]
Abstract
Anticoagulation in patients with impaired kidney function can be challenging since drugs' pharmacokinetics and bioavailability are altered in this setting. Patients with chronic kidney disease (CKD) treated with conventional anticoagulant agents [vitamin K antagonist (VKA), low-molecular weight heparin (LMWH) or unfractionated heparin (UFH)] are at high risk of bleeding events (both non-major and major clinically relevant bleeding). While anticoagulation reduces the risk of thromboembolic events, the co-existing bleeding risk and the fact that the most commonly used anticoagulation agents are eliminated via the kidneys pose additional challenges. More recently, two classes of direct oral anticoagulant agents (DOACs) have been investigated for the prevention and management of venous thromboembolic events: the direct factor Xa inhibitors rivaroxaban, apixaban and edoxaban, and the direct thrombin inhibitor dabigatran. In this review, we discuss the complex challenges and the practical considerations associated with the management of anticoagulation treatment in patients with CKD, with a special focus on DOACs.
Collapse
Affiliation(s)
- Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy.
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy.
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Karen Schreiber
- Centre for Thrombosis and Haemostasis, St. Thomas' Hospital, London, UK
- Department of Rheumatology, Copenhagen University Hospital at Rigshospitalet, Copenhagen, Denmark
| | - Roberta Fenoglio
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Simone Baldovino
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| |
Collapse
|
46
|
Bernaitis N, Ching CK, Teo SC, Chen L, Badrick T, Davey AK, Crilly J, Anoopkumar-Dukie S. Factors influencing warfarin control in Australia and Singapore. Thromb Res 2017; 157:120-125. [PMID: 28738273 DOI: 10.1016/j.thromres.2017.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 06/22/2017] [Accepted: 07/10/2017] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Warfarin is widely used for patients with non-valvular atrial fibrillation (NVAF). Variations in warfarin control, as measured by time in therapeutic range (TTR), have been reported across different regions and ethnicities, particularly between Western and Asian countries. However, there is limited data on comparative factors influencing warfarin control in Caucasian and Asian patients. Therefore, the aim of this study was to determine warfarin control and potential factors influencing this in patients with NVAF in Australia and Singapore. METHODS Retrospective data was collected for patients receiving warfarin for January to June 2014 in Australia and Singapore. TTR was calculated for individuals with mean patient TTR used for analysis. Possible influential factors on TTR were analysed including age, gender, concurrent co-morbidities, and concurrent medication. RESULTS The mean TTR was significantly higher in Australia (82%) than Singapore (58%). At both sites, chronic kidney disease significantly lowered this TTR. Further factors influencing control were anaemia and age<60years in Australia, and vascular disease, CHA2DS2-VASc score of 6, and concurrent platelet inhibitor therapy in Singapore. DISCUSSION Warfarin control was significantly higher in Australia compared to Singapore, however chronic kidney disease reduced control at both sites. The different levels of control in these two countries, together with patient factors further reducing control may impact on anticoagulant choice in these countries with better outcomes from warfarin in Australia compared to Singapore.
Collapse
Affiliation(s)
- Nijole Bernaitis
- Menzies Health Institute and Quality Use of Medicines Network, Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia
| | - Chi Keong Ching
- Cardiology Department, National Heart Centre Singapore, Singapore
| | - Siew Chong Teo
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Liping Chen
- Pharmacy Department, National Heart Centre Singapore, Singapore
| | - Tony Badrick
- RCPA Quality Assurance Programs, New South Wales, Australia
| | - Andrew K Davey
- Menzies Health Institute and Quality Use of Medicines Network, Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia
| | - Julia Crilly
- Menzies Health Institute and Quality Use of Medicines Network, Queensland, Griffith University, Queensland, Australia; Department of Emergency Medicine Gold Coast Health, Queensland, Australia
| | - Shailendra Anoopkumar-Dukie
- Menzies Health Institute and Quality Use of Medicines Network, Queensland, Griffith University, Queensland, Australia; School of Pharmacy, Griffith University, Queensland, Australia.
| |
Collapse
|
47
|
Molnar AO, Sood MM. Predicting in a predicament: Stroke and hemorrhage risk prediction in dialysis patients with atrial fibrillation. Semin Dial 2017; 31:37-47. [PMID: 28699181 DOI: 10.1111/sdi.12637] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Whether to anticoagulate dialysis patients with atrial fibrillation is a common clinical dilemma with limited high-quality data to inform decision-making. While the efficacy and safety of anticoagulation for stroke prevention in dialysis patients with atrial fibrillation has long been debated and remains unclear, the more upstream issue of stroke risk assessment from atrial fibrillation has received relatively little attention. In the general population, a handful of risk scores to help predict stroke and hemorrhage risk in the setting of atrial fibrillation are widely validated and applied in clinical practice. But are they applicable to the dialysis population? The most commonly used stroke risk scores, CHADS2 and CHA2DS2-VASC, have limited validation in the dialysis population, and when validated, have shown poor performance (c-statistics <0.70). Stroke risk scores derived in the general atrial fibrillation population may perform poorly in dialysis patients for a number of reasons. Dialysis patients have unique stroke risk factors, such as chronic inflammation and vascular calcification, and a much higher competing risk of death, none of which are accounted for in current risk scores. Further complicating the dilemma of anticoagulation is hemorrhage risk, which is known to be exceedingly high in dialysis patients. Currently available hemorrhage risk scores, such as HAS-BLED, have not been validated in dialysis patients and will likely underestimate hemorrhage risk. Moving forward, risk tools specific to the dialysis population are needed to accurately assess and balance stroke and hemorrhage risks in dialysis patients with atrial fibrillation.
Collapse
Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Canada.,Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
48
|
Lutz J, Jurk K, Schinzel H. Direct oral anticoagulants in patients with chronic kidney disease: patient selection and special considerations. Int J Nephrol Renovasc Dis 2017; 10:135-143. [PMID: 28652799 PMCID: PMC5473496 DOI: 10.2147/ijnrd.s105771] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Many patients with chronic kidney disease (CKD) receive anticoagulation or antiplatelet therapy due to atrial fibrillation, coronary artery disease, thromboembolic disease, or peripheral artery disease. The treatment usually includes vitamin K antagonists (VKAs) and/or platelet aggregation inhibitors. The direct oral anticoagulants (DOAC) inhibiting factor Xa or thrombin represent an alternative for VKAs. In patients with acute and chronic kidney disease, caution is warranted, as DOACs can accumulate as they are partly eliminated by the kidneys. Thus, they can potentially increase the bleeding risk in patients with CKD. In patients with an estimated glomerular filtration rate (eGFR) above 60 mL/min, DOACs can be used safely with greater efficacy and safety as compared to VKAs. In patients with CKD 3, DOACs are as effective as VKAs with a lower bleeding rate. The more the renal function declines, the lower is the advantage of DOACs over VKAs. Thus, use of DOACs should be avoided in patients with an eGFR below 30 mL/min, particularly, the compounds with a high renal elimination. Available data suggest that DOACs can also be used safely in older patients. In this review, use of DOACs in comparison with VKAs, heparins, and heparinoids, together with special considerations in patients with impaired renal function will be discussed.
Collapse
Affiliation(s)
- Jens Lutz
- Nephrology Department, I. Medizinische Klinik und Poliklinik
| | - Kerstin Jurk
- Center for Thrombosis and Hemostasis, Universitätsmedizin Mainz
| | - Helmut Schinzel
- Cardiopraxis Mainz, Gerinnungsambulanz, MED Facharztzentrum, Mainz, Germany
| |
Collapse
|