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Salbach C, Milles BR, Hund H, Biener M, Mueller-Hennessen M, Frey N, Katus H, Giannitsis E, Yildirim M. Effect of impaired kidney function on outcomes and treatment effects of oral anticoagulant regimes in patients with atrial fibrillation in a real-world registry. PLoS One 2024; 19:e0310838. [PMID: 39312541 PMCID: PMC11419350 DOI: 10.1371/journal.pone.0310838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 09/07/2024] [Indexed: 09/25/2024] Open
Abstract
BACKGROUND The impact of impaired kidney function on outcomes and treatment benefits of vitamin-K antagonists (VKA) versus direct oral anticoagulants (DOAC) in patients with atrial fibrillation (AF) has insufficiently been investigated in randomized controlled studies (RCTs). Most studies and registries are either biased due to incomplete enrolment of consecutive patients in large pharma industry sponsored registries, or due to short recruitment periods or incomplete assessment of important variables in national registries. METHODS This study uses data from the Heidelberg Registry of Atrial Fibrillation (HERA-FIB), a retrospective single-center registry of 10,222 consecutive patients with AF presenting to the emergency department of University Hospital of Heidelberg from June 2009 until March 2020. Rates of all-cause mortality, stroke, major bleeding and myocardial infarction (MI) were related to the presence and severity of impaired presenting kidney function, as well as to assigned treatment with VKA vs. DOAC. RESULTS The risks for all-cause mortality (HR: 3.26, p<0.001), stroke (HR: 1.58, p<0.001), major bleeding (HR: 2.28, p<0.001) and MI (HR: 2.48, p<0.001) were significantly higher in patients with an eGFR<60 ml/min at admission and increased with decreasing eGFR. After adjustment for variables of CHA2DS2VASc-score, presence of eGFR <60 ml/min remained as an independent predictor for all-cause mortality, major bleeding and MI. The hazard ratio (HR) for all-cause mortality, major bleedings and MI was significantly lower in patients receiving DOAC compared to VKA. CONCLUSION Findings from our large real-life registry confirm the data from RCTs and extend our knowledge on the effectiveness and safety of DOACs to subjects that were underrepresented in RCTs.
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Affiliation(s)
- Christian Salbach
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Barbara Ruth Milles
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Hauke Hund
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Moritz Biener
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | | | - Norbert Frey
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Hugo Katus
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Mustafa Yildirim
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Heidelberg, Germany
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Salbach C, Yildirim M, Hund H, Biener M, Müller‐Hennessen M, Frey N, Katus HA, Giannitsis E, Milles BR. Design, Rationale and Initial Findings From HERA-FIB on 10 222 Patients With Atrial Fibrillation Presenting to an Emergency Department Over An 11-Year Period. J Am Heart Assoc 2024; 13:e033396. [PMID: 38639359 PMCID: PMC11179873 DOI: 10.1161/jaha.123.033396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/21/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND For the majority of patients with atrial fibrillation (AF), disease management has improved in recent years. However, there are still populations underrepresented or excluded in current registries and randomized controlled trials. HERA-FIB (Heidelberg Registry of Atrial Fibrillation) was planned to assess real-world evidence for the prevalence, demographic characteristics and management of patients with the diagnosis of AF presenting consecutively to a chest pain unit. METHODS AND RESULTS HERA-FIB is a retrospective, observational, single-center study on patients with a diagnosis of AF presenting to a chest pain unit from June 2009 until March 2020. This article describes the structure, governance, outcome assessment, quality and data collection processes of the registry. Additionally, characteristics of populations of special interest are described. The study consecutively enrolled 10 222 patients presenting with AF to the chest pain unit of the University Hospital of Heidelberg. Clinical parameters and patient characteristics were assessed retrospectively. Outcome parameters included rates for all-cause death, stroke, myocardial infarction and major bleedings. We were able to investigate patient cohorts of special interest such as advanced chronic kidney disease, octogenarians, and those with acute coronary syndrome who are often underrepresented in current studies and randomized controlled trials. CONCLUSIONS HERA-FIB is one of the largest real-world single-center retrospective registries on patients with AF, which captures the era of transition from vitamin K antagonists to non-vitamin K oral anticoagulation regimens in clinical practice and offers the possibility to investigate patient populations usually underrepresented or excluded in current available randomized controlled trials and registries. REGISTRATION URL: https://www.clinicaltrials.gov; unique identifier: NCT05995561.
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Affiliation(s)
- Christian Salbach
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Mustafa Yildirim
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Hauke Hund
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Moritz Biener
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | | | - Norbert Frey
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Hugo A. Katus
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
| | - Barbara Ruth Milles
- Department of Internal Medicine III, CardiologyUniversity Hospital of HeidelbergHeidelbergGermany
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Schiedat F, Meuterodt B, Prull M, Aweimer A, Gotzmann M, O’Connor S, Perings C, Korth J, Lawo T, El-Battrawy I, Hanefeld C, Mügge A, Kloppe A. Comparison of infection and complication rates associated with transvenous vs. subcutaneous defibrillators in patients with stage 4 chronic kidney disease: a multicenter long-term retrospective follow-up. Front Cardiovasc Med 2024; 11:1397138. [PMID: 38660482 PMCID: PMC11040078 DOI: 10.3389/fcvm.2024.1397138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/27/2024] [Indexed: 04/26/2024] Open
Abstract
Background Patients with progressive chronic kidney disease (CKD) are at higher risk of infections and complications from cardiac implantable electronic devices (CIED). In patients with a primary or secondary prophylactic indication, implantable cardiac defibrillators (ICD) can prevent sudden cardiac deaths (SCD). We retrospectively compared transvenous-ICD (TV-ICD) and intermuscularly implanted subcutaneous-ICD (S-ICD) associated infections and complication rates together with hospitalizations in recipients with stage 4 kidney disease. Methods We retrospectively analyzed 70 patients from six German centers with stage 4 CKD who received either a prophylactic TV-ICD with a single right ventricular lead, 49 patients, or a S-ICD, 21 patients. Follow-Ups (FU) were performed bi-annually. Results The TV-ICD patients were significantly older. This group had more patients with a history of atrial arrhythmias and more were prescribed anti-arrhythmic medication compared with the S-ICD group. There were no significant differences for other baseline characteristics. The median and interquartile range of FU durations were 55.2 (57.6-69.3) months. During FU, patients with a TV-ICD system experienced significantly more device associated infections (n = 8, 16.3% vs. n = 0; p < 0.05), device-associated complications (n = 13, 26.5% vs. n = 1, 4.8%; p < 0.05) and device associated hospitalizations (n = 10, 20.4% vs. n = 1, 4.8%; p < 0.05). Conclusion In this long-term FU of patients with stage 4 CKD and an indication for a prophylactic ICD, the S-ICD was associated with significantly fewer device associated infections, complications and hospitalizations compared with TV-ICDs.
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Affiliation(s)
- Fabian Schiedat
- Department of Cardiology and Angiology, UniversityHospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany
- Department of Cardiology and Angiology at Marienhospital Gelsenkirchen, Academic Hospital of the Ruhr University Bochum, Gelsenkirchen, Germany
| | - Benjamin Meuterodt
- Department of Cardiology, Electrophysiology, Pneumology and Intensive Care Medicine, St. Marien-Hospital Luenen, Academic Hospital of the University Muenster, Luenen, Germany
| | - Magnus Prull
- Department of Cardiology, Augusta Hospital Bochum, Academic Hospital of the University Duisburg-Essen, Bochum, Germany
| | - Assem Aweimer
- Department of Cardiology and Angiology, UniversityHospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany
| | - Michael Gotzmann
- Department of Cardiology, Katholische Kliniken Bochum of the Ruhr University Bochum, Bochum, Germany
| | - Stephen O’Connor
- Department of Biomedical Engineering, City, University of London, London, United Kingdom
| | - Christian Perings
- Department of Cardiology, Electrophysiology, Pneumology and Intensive Care Medicine, St. Marien-Hospital Luenen, Academic Hospital of the University Muenster, Luenen, Germany
| | - Johannes Korth
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thomas Lawo
- Department of Cardiology, Elisabeth Hospital Recklinghausen, Recklinghausen, Germany
| | - Ibrahim El-Battrawy
- Department of Cardiology and Angiology, UniversityHospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany
- Department of Molecular and Experimental Cardiology, Institut für Forschung und Lehre (IFL), Ruhr-University Bochum, Bochum, Germany
| | - Christoph Hanefeld
- Department of Cardiology, Katholische Kliniken Bochum of the Ruhr University Bochum, Bochum, Germany
| | - Andreas Mügge
- Department of Cardiology and Angiology, UniversityHospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany
- Department of Cardiology, Katholische Kliniken Bochum of the Ruhr University Bochum, Bochum, Germany
| | - Axel Kloppe
- Department of Cardiology and Angiology, UniversityHospital Bergmannsheil Bochum of the Ruhr-University Bochum, Bochum, Germany
- Department of Cardiology and Angiology at Marienhospital Gelsenkirchen, Academic Hospital of the Ruhr University Bochum, Gelsenkirchen, Germany
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Ali A, Siddiqui AA, Ali M, Shahid I. Meta-analysis on performance of ABC and GARFIELD-AF compared to CHA 2DS 2-VASc and HAS-BLED in anticoagulated atrial fibrillation patients. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 60:74-81. [PMID: 37880043 DOI: 10.1016/j.carrev.2023.10.007] [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: 08/09/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND When high thromboembolic and bleeding risks coexist, the former tends to influence physicians' decision making for anti-coagulation therapy. However, the ideal is to weigh the risk of major bleeding and stroke together to ensure effective anti-coagulation treatment, which is a limitation of traditional guideline recommended CHA2DS2-VASc and HAS-BLED. This meta-analysis assesses the performance of the two new scores - ABC and GARFIELD-AF compared to CHA2DS2-VASc and HAS-BLED for major bleeding and stroke outcomes in patients with atrial fibrillation (AF) on anticoagulation therapy. METHODS MEDLINE and Cochrane central were searched from 2010 to February 2023 that compared GARFIELD-AF and/or ABC with CHA2DS2-VASc and/or HAS-BLED scores using C-statistics to assess their discriminative ability. RESULTS 12 studies were included in this meta-analysis. When assessing stroke risk prediction, GARFIELD-AF stroke (C-Statistic: 0.71; 95 % CI: 0.70-0.72; I2 = 0 %, p < 0.05) was found to be significantly better than ABC-stroke (C-Statistic: 0.67; 95 % CI: 0.65-0.68; I2 = 0 %, p < 0.05), and CHA2DS2-VASc (C-Statistic: 0.64; 95 % CI: 0.60-0.67; I2 = 92 %, p < 0.05). Additionally, when assessing bleeding risk prediction, ABC-bleeding (C-Statistic: 0.66; 95 % CI: 0.61-0.70; I2 = 84 %, p < 0.05), GARFIELD-AF (C-Statistic: 0.64; 95 % CI: 0.60-0.68; I2 = 95 %, p < 0.05), and HAS-BLED (C-Statistic: 0.64; 95 % CI: 0.62-0.66; I2 = 85 %, p < 0.05) all showed equivalent performances. CONCLUSION The GARFIELD-AF stroke score showed superior performance to the well-established CHA2DS2-VASc score as well as the ABC-stroke score. Therefore, new guidelines should favor GARFIELD-AF use in clinical practice.
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Affiliation(s)
- Abraish Ali
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan.
| | - Asad Ali Siddiqui
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Mirha Ali
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Izza Shahid
- Division of Preventive Cardiology, Houston Methodist Academic Institute, Houston, TX, USA
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Ha JT, Freedman SB, Kelly DM, Neuen BL, Perkovic V, Jun M, Badve SV. Kidney Function, Albuminuria, and Risk of Incident Atrial Fibrillation: A Systematic Review and Meta-Analysis. Am J Kidney Dis 2024; 83:350-359.e1. [PMID: 37777059 DOI: 10.1053/j.ajkd.2023.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/19/2023] [Accepted: 07/31/2023] [Indexed: 10/02/2023]
Abstract
RATIONALE & OBJECTIVE Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist. However, it is not known whether CKD is an independent risk factor for incident AF. Therefore, we evaluated the association between markers of CKD-estimated glomerular filtration rate (eGFR) and albuminuria-and incident AF. STUDY DESIGN Systematic review and meta-analysis of cohort studies and randomized controlled trials. SETTING & STUDY POPULATIONS Participants with measurement of eGFR and/or albuminuria who were not receiving dialysis. SELECTION CRITERIA FOR STUDIES Cohort studies and randomized controlled trials were included that reported incident AF risk in adults according to eGFR and/or albuminuria. ANALYTICAL APPROACH Age- or multivariate-adjusted risk ratios (RRs) for incident AF were extracted from cohort studies, and RRs for each trial were derived from event data. RRs for incident AF were pooled using random-effects models. RESULTS 38 studies involving 28,470,249 participants with 530,041 incident AF cases were included. Adjusted risk of incident AF was greater among participants with lower eGFR than those with higher eGFR (eGFR<60 vs≥60mL/min/1.73m2: RR, 1.43; 95% CI, 1.30-1.57; and eGFR<90 vs≥90mL/min/1.73m2: RR, 1.42; 95% CI, 1.26-1.60). Adjusted incident AF risk was greater among participants with albuminuria (any albuminuria vs no albuminuria: RR, 1.43; 95% CI, 1.25-1.63; and moderately to severely increased albuminuria vs normal to mildly increased albuminuria: RR, 1.64; 95% CI, 1.31-2.06). Subgroup analyses showed an exposure-dependent association between CKD and incident AF, with the risk increasing progressively at lower eGFR and higher albuminuria categories. LIMITATIONS Lack of patient-level data, interaction between eGFR and albuminuria could not be evaluated, possible ascertainment bias due to variation in the methods of AF detection. CONCLUSIONS Lower eGFR and greater albuminuria were independently associated with increased risk of incident AF. CKD should be regarded as an independent risk factor for incident AF. PLAIN-LANGUAGE SUMMARY Irregular heartbeat, or atrial fibrillation (AF), is the commonest abnormal heart rhythm. AF occurs commonly in people with chronic kidney disease (CKD), and CKD is also common in people with AF. However, CKD in not widely recognized as a risk factor for new-onset or incident AF. In this research, we combined data on more than 28 million participants in 38 studies to determine whether CKD itself increases the chances of incident AF. We found that both commonly used markers of kidney disease (estimated glomerular filtration rate and albuminuria, ie, protein in the urine) were independently associated with a greater risk of incident AF. This finding suggests that CKD should be recognized as an independent risk factor for incident AF.
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Affiliation(s)
- Jeffrey T Ha
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Renal Medicine, St George Hospital, Sydney, NSW, Australia
| | - S Ben Freedman
- Heart Research Institute, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Dearbhla M Kelly
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Global Brain Health Institute, Trinity College Dublin, Ireland
| | - Brendon L Neuen
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Min Jun
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Sunil V Badve
- The George Institute for Global Health, Sydney, NSW, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Department of Renal Medicine, St George Hospital, Sydney, NSW, Australia.
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Kreutz R, Deray G, Floege J, Gwechenberger M, Hahn K, Luft AR, Persson P, Axthelm C, Beer JH, Bergler-Klein J, Lellouche N, Taggeselle J, Beyer-Westendorf J. Risk Profiles and Treatment Patterns in Atrial Fibrillation Patients with Chronic Kidney Disease Receiving or not Receiving Anticoagulation Therapy. TH OPEN 2024; 8:e106-e113. [PMID: 38406259 PMCID: PMC10890905 DOI: 10.1055/s-0044-1780529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 12/21/2023] [Indexed: 02/27/2024] Open
Abstract
Background Patients with atrial fibrillation (AF) and chronic kidney disease (CKD) are at high risk for both thromboembolism and bleeding events. The latter induces a potential reason for withholding oral anticoagulation (OAC) despite an indication for prophylaxis of thromboembolic events. Methods AF patients with CKD (estimated glomerular filtration [eGFR] rate between 15 and 49 mL/min per 1.73 m 2 ) were included in a prospective international registry in Europe between 2016 and 2020, that is, XARENO (factor XA inhibition in renal patients with nonvalvular atrial fibrillation observational registry). The study enrolled adult patients treated at the discretion of physicians with rivaroxaban, vitamin K antagonists (VKA), or without OAC (w/oOAC). Here, we report a prespecified explorative baseline comparison between patients receiving OAC or no OAC within XARENO. Results In total, 1,544 patients (mean age: 78.2 years, mean eGFR: 36.2 mL/min) were studied (rivaroxaban n = 764, VKA n = 691, w/oOAC n = 89). Patients in the w/oOAC group were older and had a similar stroke (mean CHA 2 DS 2 -VASc score 4.0) but higher bleeding risk (mean modified Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly score 2.5 vs. 1.8) compared with the OAC groups. The distribution of comorbidities including hypertension, diabetes, and heart failure was similar. Treatment with antiplatelet drugs was fivefold more frequent in the w/oOAC group. Conclusion Only 5.8% of the overall population of AF patients with advanced CKD received no OAC. These patients were older and had a higher bleeding risk, which might explain this decision, but which contrasts with the more frequent use of antiplatelet drugs in this vulnerable group of patients.
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Affiliation(s)
- Reinhold Kreutz
- Institute of Clinical Pharmacology and Toxicology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Gilbert Deray
- Department of Nephrology, Pitié-Salpêtrière Hospital, Paris 6 University, Paris, France
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Marianne Gwechenberger
- Division of Cardiology, University Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Kai Hahn
- Nephrologische Praxis, Dortmund, Germany
| | - Andreas R. Luft
- Center for Neurology and Rehabilitation, Klinik für Neurologie, Universitätsspital Zürich, Switzerland and Cereneo, Vitznau, Switzerland
| | - Pontus Persson
- Institut für Vegetative Physiologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | - Juerg Hans Beer
- Department Innere Medizin, Baden Switzerland and Center of Molecular Cardiology, Kantonsspital Baden, University of Zürich, Zürich, Switzerland
| | - Jutta Bergler-Klein
- Division of Cardiology, University Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Nicolas Lellouche
- Service de Cardiologie 1, Centre Hospitalier Universitaire Henri Mondor, Créteil, France
| | | | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division Haematology, Department of Medicine I, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
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Zhang J, Hu Z, Tan Y, Ye J. Causal relationship from heart failure to kidney function and CKD: A bidirectional two-sample mendelian randomization study. PLoS One 2023; 18:e0295532. [PMID: 38079381 PMCID: PMC10712866 DOI: 10.1371/journal.pone.0295532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Heart Failure (HF) is a widespread condition that affects millions of people, and it is caused by issues with the heart and blood vessels. Even though we know hypertension, coronary artery disease, obesity, diabetes, and genetics can increase the risk of HF and Chronic Kidney Disease (CKD), the exact cause of these conditions remains a mystery. To bridge this gap, we adopted Mendelian Randomization (MR), which relies on genetic variants as proxies. METHODS We used data from European populations for our Bidirectional Two-Sample MR Study, which included 930,014 controls and 47,309 cases of HF from the HERMES consortium, as well as 736,396 controls and 51,256 cases of CKD. We also employed several MR variations, including MR-Egger, Inverse Variance Weighted (IVW), and Weighted Median Estimator (WME), to guarantee the results were accurate and comprehensive.). RESULTS In this study, the MR analysis found that individuals with a genetic predisposition for HF have an elevated risk of CKD. Our study revealed a significant association between the genetic prediction of HF and the risk of CKD, as evidenced by the IVW method [with an odds ratio (OR) of 1.12 (95% CI, 1.03-1.21), p = 0.009] and the WME [with an OR of 1.14 (95% CI, 1.03-1.26), p = 0.008]. This causal relationship remained robust even after conducting MR analysis while adjusting for the effects of diabetes and hypertension, yielding ORs of 1.13 (IVW:95% CI, 1.03-1.23), 1.12 (MR-Egger: 95% CI, 0.85-1.48), and 1.15 (WME:95% CI, 1.04-1.27) (p = 0.008). However, in the reverse analysis aiming to explore CKD and renal function as exposures and HF as the outcome, we did not observe a statistically significant causal link between CKD and HF. CONCLUSION Our study demonstrates the significance of HF in CKD progression, thus having meaningful implications for treatment and the potential for discovering new therapies. To better understand the relationship between HF and CKD, we need to conduct research in a variety of populations.
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Affiliation(s)
- Junyu Zhang
- Institute of Traditional Chinese Medicine Diagnostics, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Zhixi Hu
- Institute of Traditional Chinese Medicine Diagnostics, Hunan University of Chinese Medicine, Changsha, Hunan, China
- Hunan Provincial Key Laboratory of Diagnostic Research in Chinese Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Yuquan Tan
- Institute of Traditional Chinese Medicine Diagnostics, Hunan University of Chinese Medicine, Changsha, Hunan, China
- Hunan Provincial Key Laboratory of Diagnostic Research in Chinese Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Jiahao Ye
- Institute of Traditional Chinese Medicine Diagnostics, Hunan University of Chinese Medicine, Changsha, Hunan, China
- Hunan Provincial Key Laboratory of Diagnostic Research in Chinese Medicine, Hunan University of Chinese Medicine, Changsha, Hunan, China
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Hahn K, Lamparter M. Prescription of DOACs in Patients with Atrial Fibrillation at Different Stages of Renal Insufficiency. Adv Ther 2023; 40:4264-4281. [PMID: 37594666 PMCID: PMC10499752 DOI: 10.1007/s12325-023-02544-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/04/2023] [Indexed: 08/19/2023]
Abstract
Atrial fibrillation (AF) and renal insufficiency often coexist and are increasingly prevalent with advancing age. Both the risk of thromboembolic events and bleeding propensity are higher in patients with AF and impaired renal function versus those with good renal health. Direct oral anticoagulants (DOACs) are being increasingly preferred over vitamin K antagonists (VKAs) in the treatment of patients with AF and impaired renal function as VKAs may accelerate progression of chronic kidney disease. DOACs, however, are eliminated by the kidneys to varying degrees, and their dosages must be adapted in accordance with renal function. Since creatinine clearance (CrCl) monitoring is recommended in patients with AF receiving DOAC therapy, CrCl must be routinely monitored in patients at the start and during the course of anticoagulation to avoid deviation from Summary of Product Characteristics dosage specifications. This review article provides an overview of current knowledge on the selection and dose of DOACs including apixaban, dabigatran, edoxaban and rivaroxaban in AF patients at different stages of renal insufficiency, with a special focus on elderly patients with comorbidities and receiving multiple medications. The groups discussed in this review include patients with varying levels of CrCl including hyperfiltration or CrCl > 90 ml/min, CrCl < 90-50 ml/min, CrCl < 50-30 ml/min, CrCl < 30-15 ml/min and end-stage renal disease or on dialysis.
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Affiliation(s)
- Kai Hahn
- Praxis für Nieren- und Hochdruckkrankheiten Dr. Hahn, Märkische Straße 237, 44141, Dortmund, Germany.
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Bao MQ, Shu GJ, Chen CJ, Chen YN, Wang J, Wang Y. Association of chronic kidney disease with all-cause mortality in patients hospitalized for atrial fibrillation and impact of clinical and socioeconomic factors on this association. Front Cardiovasc Med 2022; 9:945106. [PMID: 36505361 PMCID: PMC9729356 DOI: 10.3389/fcvm.2022.945106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/03/2022] [Indexed: 11/25/2022] Open
Abstract
Background Atrial fibrillation (AF) and chronic kidney disease (CKD) often co-occur, and many of the same clinical factors and indicators of socioeconomic status (SES) are associated with both diseases. The effect of the estimated glomerular filtration rate (eGFR) on all-cause mortality in AF patients and the impact of SES on this relationship are uncertain. Materials and methods This retrospective study examined 968 patients who were admitted for AF. Patients were divided into four groups based on eGFR at admission: eGFR-0 (normal eGFR) to eGFR-3 (severely decreased eGFR). The primary outcome was all-cause mortality. Cox regression analysis was used to identify the effect of eGFR on mortality, and subgroup analyses to determine the impact of confounding factors. Results A total of 337/968 patients (34.8%) died during follow-up. The average age was 73.70 ± 10.27 years and there were 522 males (53.9%). More than 39% of these patients had CKD (eGFR < 60 mL/min/1.73 m2), 319 patients with moderately decreased eGFR and 67 with severely decreased eGFR. After multivariate adjustment and relative to the eGFR-0 group, the risk for all-cause death was greater in the eGFR-2 group (HR = 2.416, 95% CI = 1.366-4.272, p = 0.002) and the eGFR-3 group (HR = 4.752, 95% CI = 2.443-9.242, p < 0.00001), but not in the eGFR-1 group (p > 0.05). Subgroup analysis showed that moderately to severely decreased eGFR only had a significant effect on all-cause death in patients with low SES. Conclusion Moderately to severely decreased eGFR in AF patients was independently associated with increased risk of all-cause mortality, especially in those with lower SES.
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Affiliation(s)
- Min-qiang Bao
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China,Department of Neurology, Xuancheng People’s Hospital, Xuancheng, China
| | - Gui-jun Shu
- Department of Oncology, Xuancheng People’s Hospital, Xuancheng, China
| | - Chuan-jin Chen
- Department of Medical Record Management, Xuancheng People’s Hospital, Xuancheng, China
| | - Yi-nong Chen
- Department of Neurology, Xuancheng People’s Hospital, Xuancheng, China
| | - Jie Wang
- Department of Neurology, Xuancheng People’s Hospital, Xuancheng, China
| | - Yu Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China,*Correspondence: Yu Wang,
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10
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Ambrosino P, Fuschillo S, Accardo M, Mosella M, Molino A, Spedicato GA, Motta A, Maniscalco M. Fractional Exhaled Nitric Oxide (FeNO) in Patients with Stable Chronic Obstructive Pulmonary Disease: Short-Term Variability and Potential Clinical Implications. J Pers Med 2022; 12:1906. [PMID: 36422082 PMCID: PMC9699194 DOI: 10.3390/jpm12111906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND The use of fractional exhaled nitric oxide (FeNO) has been proposed for identifying and monitoring eosinophilic airway inflammation in chronic obstructive pulmonary disease (COPD). To explore the clinical utility of FeNO in COPD, we aimed to assess its short-term variability in a clinically stable COPD cohort. METHODS Consecutive COPD patients, formerly smokers, underwent FeNO assessment at the baseline and six time-points through serial sampling spaced 3 days apart. RESULTS A total of 41 patients (mean age 72.9, 87.8% males) showed a median baseline value of FeNO of 11.7 (8.0-16.8) ppb. A weak linear relationship was documented between baseline FeNO values and both eosinophil counts (r = 0.341, p = 0.029) and the percentage of eosinophils (r = 0.331, p = 0.034), confirmed in multiple linear regressions after adjusting for steroid use. The overall individual variability of FeNO between time-points was 3.90 (2.53-7.29) ppb, with no significant difference in the distribution of FeNO values measured at different time-points (p = 0.204). A total of 28 (68.3%) patients exhibited FeNO always below the 25 ppb cut-off at all determinations, while the remining 13 (31.7%) had at least one value above the established limit. Interestingly, none of these 13 participants had FeNO stably above 25 ppb, all showing at least one normal value during serial sampling. Compared to these patients with more fluctuating values, the 28 with stably normal FeNO only exhibited a significantly higher body weight (80.0 ± 18.2 kg vs. 69.0 ± 8.8 kg, p = 0.013) and body mass index (29.7 ± 6.5 kg/m2 vs. 25.9 ± 3.7 kg/m2, p = 0.026), confirmed in multiple logistic regressions after adjusting for major potential confounders. CONCLUSIONS A certain degree of FeNO variability, apparently unrelated to eosinophil counts but somehow influenced by body weight, must be considered in COPD patients. Further studies are needed to clarify whether this biomarker may be effectively used to plan more personalized pharmacological and rehabilitation strategies in this clinical setting.
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Affiliation(s)
- Pasquale Ambrosino
- Istituti Clinici Scientifici Maugeri IRCCS, Cardiac Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy
| | - Salvatore Fuschillo
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy
| | - Mariasofia Accardo
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy
| | - Marco Mosella
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy
| | - Antonio Molino
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy
| | | | - Andrea Motta
- Institute of Biomolecular Chemistry, National Research Council, 80078 Pozzuoli, Italy
| | - Mauro Maniscalco
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy
- Department of Clinical Medicine and Surgery, Federico II University, 80131 Naples, Italy
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11
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Bhat A, Gan GCH, Chen HHL, Nawaz S, Khanna S, Dobbins T, Tan TC. Prognostic implications of traditional and non-traditional cardiovascular risk factor profiles in patients with non-valvular atrial fibrillation. Eur J Clin Invest 2022; 52:e13799. [PMID: 35460264 DOI: 10.1111/eci.13799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a prevalent disease with associated mortality risk, mediated in large part through its associated cardiovascular risk factors. Standard modifiable cardiovascular risk factors (SMuRFs; hypercholesterolaemia, hypertension, diabetes and smoking) are established drivers of cardiovascular disease; however, the importance of non-traditional mediators of cardiovascular risk (NTRFs) such as chronic renal impairment, obstructive sleep apnoea and obesity is emerging. The differential impact of these risk factors on outcomes in patients with AF is not well studied. METHODS Consecutive patients admitted to our service between January 2013 and January 2018 with a primary diagnosis of non-valvular AF were assessed. Assessment of demographic, anthropometric, risk factor profile and pharmacotherapeutics was performed. The clinical course of these patients was followed for up to five years for the composite outcome of all-cause death and major adverse cardiovascular events. RESULTS Of the 1010 patients (62.29 ± 16.81 years, 51% men) included, 154 (15%) had no risk factors, 478 (47%) had only SMuRFs, 59 (6%) had only NTRFs and 319 (32%) had both SMuRFs and NTRFs. Over a mean follow-up period of 33.18 ± 21.27 months, a total of 288 patients met the composite outcome. On Cox regression, the coexistence of SMuRFs and NTRFs was an independent predictor of the composite outcome (HR 1.40; 95%CI 1.09-1.82, p = .01). Other independent predictors included age, heart failure, CHA2 DS2 VASc score, persistent AF and anaemia. CONCLUSIONS The presence of both SMuRFs and NTRFs has prognostic implications in patients with non-valvular AF.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Sumreen Nawaz
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Shaun Khanna
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Timothy Dobbins
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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12
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Liampas E, Kartas A, Samaras A, Papazoglou AS, Moysidis DV, Vrana E, Botis M, Papanastasiou A, Baroutidou A, Vouloagkas I, Karagiannidis E, Akrivos E, Tsalikakis D, Fyntanidou V, Karvounis H, Tzikas A, Giannakoulas G. Renal function and mortality in patients with atrial fibrillation. J Cardiovasc Med (Hagerstown) 2022; 23:430-438. [PMID: 35763763 DOI: 10.2459/jcm.0000000000001308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIM The aim of this study is to examine the association of the presence of chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) values with mortality in patients with atrial fibrillation. METHODS This posthoc analysis of a randomized controlled trial consisted of hospitalized patients with atrial fibrillation who were followed up for a median of 2.7 years after discharge. Kaplan-Meier curves, multivariate Cox-regression and spline curves were utilized to assess the association of CKD, CKD stages 2-5 according to the KDOQI guidelines, and the continuum of eGFR values with the primary outcome of all-cause death, and the secondary outcome of cardiovascular mortality. RESULTS Out of 1064 hospitalized patients with atrial fibrillation, 465 (43.7%) had comorbid CKD. The presence of CKD was associated with an increased risk for both all-cause and cardiovascular mortality following hospitalization [adjusted hazard ratio (aHR): 1.60; 95% confidence intervals (95% CIs): 1.25-2.05 and aHR: 1.74; 95% CI: 1.30-2.33, respectively]. The aHRs for all-cause mortality in CKD stages 2-5, as compared with CKD stage 1 were 2.18, 2.62, 4.20 and 3.38, respectively (all P < 0.05). In spline curve analyses, eGFR values lower than 50 ml/min/1.73 m2 were independent predictors of higher all-cause and cardiovascular mortality. CONCLUSION In recently hospitalized patients with atrial fibrillation, the presence of CKD was independently associated with decreased survival, which was significant across CKD stages 2-5, as compared with CKD stage 1. Values of eGFR lower than 50 ml/min/1.73 m2 were incrementally associated with worse prognosis.
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Affiliation(s)
| | | | | | | | | | - Eleni Vrana
- First Department of Cardiology, AHEPA University Hospital
| | - Michail Botis
- First Department of Cardiology, AHEPA University Hospital
| | | | | | | | | | | | - Dimitrios Tsalikakis
- Laboratory of Computing, Medical Informatics and Biomedical Imaging Technologies, School of Medicine
| | - Varvara Fyntanidou
- Anesthesiology Department, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki
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13
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Vamos M, Oldgren J, Nam GB, Lip GYH, Calkins H, Zhu J, Ueng KC, Ludwigs U, Wieloch M, Stewart J, Hohnloser SH. Dronedarone vs. placebo in patients with atrial fibrillation or atrial flutter across a range of renal function: a post hoc analysis of the ATHENA trial. EUROPEAN HEART JOURNAL - CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:363-371. [PMID: 34958366 PMCID: PMC9175188 DOI: 10.1093/ehjcvp/pvab090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/03/2021] [Accepted: 12/22/2021] [Indexed: 12/04/2022]
Abstract
Aims Use of antiarrhythmic drugs (AADs) in patients with chronic kidney disease (CKD) is challenging owing to issues with renal clearance, drug accumulation, and increased proarrhythmic risks. Because CKD is a common comorbidity in patients with atrial fibrillation/atrial flutter (AF/AFL), it is important to establish the efficacy and safety of AAD treatment in patients with CKD. Methods and results Dronedarone efficacy and safety in individuals with AF/AFL and varying renal functionality [estimated glomerular filtration rate (eGFR): ≥60, ≥45 and <60, and <45 mL/min] was investigated in a post hoc analysis of ATHENA (NCT00174785), a randomized, double-blind trial of dronedarone vs. placebo in patients with paroxysmal or persistent AF/AFL plus additional cardiovascular (CV) risk factors. Log-rank testing and Cox regression were used to compare the incidence of endpoints between treatments. Overall, 4588 participants were enrolled from the trial. There was no interaction between treatment group and baseline eGFR assessed as a continuous variable (P = 0.743) for the first CV hospitalization or death from any cause (primary outcome). This outcome was lower with dronedarone vs. placebo across a wide range of renal function. First CV hospitalization and first AF/AFL recurrence were both lower in the two least renally impaired subgroups with dronedarone vs. placebo. Treatment emergent adverse events leading to treatment discontinuation were more frequent with dronedarone vs. placebo and occurred more often in patients with severe renal impairment. Conclusion Dronedarone is an effective AAD in patients with AF/AFL and CV risk factors across a wide range of renal function.
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Affiliation(s)
- Mate Vamos
- Cardiac Electrophysiology Division, Department of Internal Medicine, University of Szeged , Szeged , Hungary
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University , Uppsala , Sweden
| | - Gi-Byoung Nam
- Asan Medical Center, University of Ulsan College of Medicine , Seoul , South Korea
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University , Baltimore, MD , USA
| | - Jun Zhu
- Fuwai Hospital, CAMS & PUMC , Beijing , China
| | - Kwo-Chang Ueng
- Division of Cardiology, Department of Internal Medicine, Chung-Shan Medical University Hospital , Taichung City , Taiwan
| | | | - Mattias Wieloch
- Sanofi , Paris , France
- Department of Clinical Sciences Malmö, Lund University , Malmö , Sweden
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14
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McCullough PA, Amin A, Pantalone KM, Ronco C. Cardiorenal Nexus: A Review With Focus on Combined Chronic Heart and Kidney Failure, and Insights From Recent Clinical Trials. J Am Heart Assoc 2022; 11:e024139. [PMID: 35616212 PMCID: PMC9238695 DOI: 10.1161/jaha.121.024139] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The cardiorenal nexus encompasses a bidirectional relationship between the heart and the kidneys. Chronic abnormalities in cardiac function can lead to progressive kidney disease, and chronic kidney disease can lead to progressively decreasing cardiac function and increasing risk of cardiovascular disease, including heart failure. About 15% of US adults have chronic kidney disease, 2% have heart failure, and 9% have cardiovascular disease. Prevalence rates of chronic kidney disease, cardiovascular disease, and associated morbidities such as type 2 diabetes are expected to increase with an aging population. Observational studies provide evidence for the cardiorenal nexus. Follow-up data from placebo arms of clinical trials in chronic kidney disease or cardiovascular disease show higher rates of renal and cardiovascular outcome events in patient subgroups with type 2 diabetes than in those without type 2 diabetes. The cardiorenal syndromes develop along an interlinked pathophysiological trajectory that requires a holistic, collaborative approach involving a multidisciplinary team. There is now a compendium of treatment options. Greater understanding of the underlying pathophysiology of the cardiorenal nexus will support optimization of the management of these interlinked disease states.
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Affiliation(s)
| | - Alpesh Amin
- Department of MedicineUniversity of California Irvine School of MedicineOrangeCA
| | | | - Claudio Ronco
- International Renal Research Institute of VicenzaItaly
- Department of Nephrology, Dialysis and TransplantationSan Bortolo HospitalVicenzaItaly
- Department of Medicine (DIMED)Università di PadovaPaduaItaly
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15
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Ding WY, Potpara TS, Blomström-Lundqvist C, Boriani G, Marin F, Fauchier L, Lip GYH. Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry. Eur J Clin Invest 2022; 52:e13745. [PMID: 35000206 PMCID: PMC9287022 DOI: 10.1111/eci.13745] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. METHODS We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. RESULTS A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p < .001. Over 24 months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01-1.14] per 10 ml/min/1.73 m2 decrease), that was most notable in patients with eGFR <30 ml/min/1.73 m2 (HR 2.21 [95% CI, 1.23-3.99] compared to eGFR ≥90 ml/min/1.73 m2 ). CONCLUSION A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBERCV, Murcia, Spain
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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16
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Zeymer U, Bonnemeier H, Wanner C. [Safety and effectiveness of oral anticoagulation in patients with atrial fibrillation and renal insufficiency - a real-world perspective]. Dtsch Med Wochenschr 2022; 147:617-624. [PMID: 35545071 DOI: 10.1055/a-1792-7094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Non-vitamin-K dependent oral anti-coagulants (NOAC) are the current therapeutic standard for preventing strokes in patients with atrial fibrillation (AF) and should be preferred over vitamin K antagonists (VKA) in this indication. This recommendation applies also to patients with VHF and concomitant chronic kidney disease (CKD). Real World Evidence (RWE), i. e., structured data from clinical practice, extends and confirms the clinical evidence generated in more formalized clinical trials with NOAC and VKA. In addition, RWE in respect to the indication showed that the superiority of NOAC versus the VKA warfarin can also be extrapolated to phenprocoumon, the commonly used VKA in Germany. Furthermore, data include evidence that the typical progression of CKD appears to be less pronounced in individuals treated with NOAC compared to those treated with VKA.
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Affiliation(s)
- Uwe Zeymer
- Medizinische Klinik B, Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin; Klinikum der Stadt Ludwigshafen am Rhein
| | - Hendrik Bonnemeier
- Klinik für Innere Medizin III, Kardiologie, Angiologie, Intensivmedizin; Universitätsklinikum Schleswig-Holstein, Kiel
| | - Christoph Wanner
- Medizinische Klinik I, Nephrologie; Universitätsklinikum Würzburg
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17
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Ocak G, Khairoun M, Khairoun O, Bos WJW, Fu EL, Cramer MJ, Westerink J, Verhaar MC, Visseren FL. Chronic kidney disease and atrial fibrillation: A dangerous combination. PLoS One 2022; 17:e0266046. [PMID: 35390012 PMCID: PMC8989340 DOI: 10.1371/journal.pone.0266046] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/12/2022] [Indexed: 11/19/2022] Open
Abstract
Background Chronic kidney disease (CKD) and atrial fibrillation (AF) are both risk factors for bleeding, stroke and mortality. The aim of our study was to investigate the interaction between CKD and atrial fibrillation and outcomes. Methods We included 12,394 subjects referred to the University Medical Center Utrecht (the Netherlands) from September 1996 to February 2018 for an out-patient visit (Utrecht Cardiovascular Cohort Second Manifestation of Arterial disease cohort). Hazard ratios (HRs) with 95% confidence intervals (CIs) for bleeding, ischemic stroke or mortality were calculated with Cox proportional hazard analyses. Presence of interaction between AF and CKD was examined by calculating the relative excess risk due to interaction (RERI), the attributable proportion (AP) due to interaction and the synergy index (S). Results Of the 12,394 patients, 699 patients had AF, 2,752 patients had CKD and 325 patients had both AF and CKD. Patients with both CKD and AF had a 3.0-fold (95% CI 2.0–4.4) increased risk for bleeding, a 4.2-fold (95% CI 3.0–6.0) increased ischemic stroke risk and a 2.2-fold (95% CI 1.9–2.6) increased mortality risk after adjustment as compared with subjects without atrial fibrillation and CKD. We did not find interaction between AF and CKD for bleeding and mortality. However, we found interaction between AF and CKD for ischemic stroke risk (RERI 1.88 (95% CI 0.31–3.46), AP 0.45 (95% CI 0.17–0.72) and S 2.40 (95% CI 1.08–5.32)). Conclusion AF and CKD are both associated with bleeding, ischemic stroke and mortality. There is a positive interaction between AF and CKD for ischemic stroke risk, but not for bleeding or mortality.
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Affiliation(s)
- Gurbey Ocak
- Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, the Netherlands
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- * E-mail:
| | - Meriem Khairoun
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Othman Khairoun
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Willem Jan W. Bos
- Department of Internal Medicine, Sint Antonius Hospital, Nieuwegein, the Netherlands
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Edouard L. Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Maarten J. Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marianne C. Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank L. Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
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18
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Ramkumar S, Kawakami H, Wong E, Nolan M, Marwick TH. Cost-effectiveness of Screening for Paroxysmal Atrial Fibrillation in Patients undergoing Echocardiography. Intern Med J 2022; 53:760-772. [PMID: 35377542 DOI: 10.1111/imj.15769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 01/14/2022] [Accepted: 03/29/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare the cost-effectiveness of unselected electrocardiographic (ECG) screening for atrial fibrillation (AF), and selective screening based on an abnormal echocardiogram. METHODS Two strategies of portable ECG screening for AF were compared in the base case of a hypothetical asymptomatic 65-year-old man (CHA2 DS2 -VASC=3 based on hypertension and diabetes mellitus) with previous echocardiography but without a cause for AF (eg. mitral valve disease, LV dysfunction). With age-based screening (AgeScreen, 3% AF detection rate) all patients underwent ECG. With imaging-guided screening (ImagingScreen; 5% detection rate), only patients with left atrial volume (LA) ≥34ml/m2 and LA reservoir strain <34% or LV global longitudinal strain (GLS)>-18% underwent ECG screening. A Markov model was informed by published transition probabilities, costs and quality-adjusted life years (QALY). Costs, effects and incremental cost-effectiveness ratio (ICER) were assessed for each screening strategy over a 20 year period. The willingness-to-pay threshold was $53,000/QALY. RESULTS ImagingScreen dominated AgeScreen, with a lower cost ($54,823 vs $57,842) and better outcome (11.56 vs 11.52 QALY over 20 years). Monte Carlo simulation demonstrated that 61% of observations were more efficacious with ImagingScreen, with cost below willingness-to-pay. The main cost determinants were annual costs of stroke or heart failure and AF detection rates. ImagingScreen was more cost-effective for AF detection rates up to 14%, and more cost-effective across a range of annual stroke ($24,000-$102,000) and heart failure ($4,000-$12,000) costs. CONCLUSION In patients with a previous echocardiogram, AF screening of those with baseline clinical and imaging risk parameters is more cost-effective than age-based screening. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Satish Ramkumar
- Baker Heart and Diabetes Institute, Melbourne, Australia.,School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia.,Monash Heart, Monash Health, Melbourne, Australia
| | | | - Edmond Wong
- Monash Heart, Monash Health, Melbourne, Australia
| | - Mark Nolan
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Australia.,School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
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19
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Wang J, Zhang T, Yang YM, Zhu J, Zhang H, Shao XH. Relationship between creatinine clearance and clinical outcomes in Chinese emergency patients with atrial fibrillation. Ann Noninvasive Electrocardiol 2022; 27:e12942. [PMID: 35239203 PMCID: PMC9107078 DOI: 10.1111/anec.12942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 12/02/2022] Open
Abstract
Background Few real‐world data on the relation between creatinine clearance (CrCl) and adverse clinical outcomes in Chinese emergency department (ED) patients with nonvalvular atrial fibrillation (AF). Methods In this prospective, observational, multicenter AF study, enrolled AF patients presenting to an ED at 20 hospitals in China from November 2008 to October 2011, with a follow‐up of 12 month. A total of 863 AF patients with CrCl data were analyzed, and patients were categorized as CrCl ≥ 80, 50 ≤ CrCl < 80, 30 ≤ CrCl < 50, and CrCl < 30(ml/min). Outcomes of analyses were all‐cause death, cardiovascular death, thromboembolism (TE), and major bleeding. Results Among the whole patients, 126(14.6%) patients died during 12‐month follow‐up, 53(40.2%) among CrCl < 30 ml/min group, and 48(16.2%), 22(6.5%), and 3(3.2%) among 30 ≤ CrCl50, 50 ≤ Crl < 80, and CrCl ≥ 80 ml/min groups, respectively (p < 0.001). Cardiovascular death and TE rates also increased with decreasing CrCl. On multivariate analysis, patients with CrCl < 30 ml/min were associated with higher risks of all‐cause death (HR 5.567; 95%CI1.618–19.876; p = .007) and higher cardiovascular death (HR11.939; 95%CI1.439–99.031; p = .022) as compared with CrCl≥80 ml/min category. Nevertheless, for TE and major bleeding risk, CrCl groups showed no significant difference after adjustment for variables in CHA2DS2‐VASc score and status of warfarin prescription in our cohort. Conclusions In Chinese ED nonvalvular AF patients, incidence rates of death increased with reducing CrCl across the whole range of renal function. CrCl < 30 ml/min was associated with all‐cause death, cardiovascular death, but not for TE and major bleeding.
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Affiliation(s)
- Juan Wang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Zhang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan-Min Yang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center of Cardiovascular Diseases, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhu
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Han Zhang
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xing-Hui Shao
- Emergency Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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20
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Pérez AG, Balabanova Y, Sáez ME, Brobert G, García Rodríguez LA. Renal decline in patients with non-valvular atrial fibrillation treated with rivaroxaban or warfarin: A population-based study from the United Kingdom. Int J Cardiol 2022; 352:165-171. [PMID: 35122912 DOI: 10.1016/j.ijcard.2022.01.063] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Reports suggest that renal decline is greater among patients with non-valvular atrial fibrillation (NVAF) treated chronically with warfarin vs. some non-vitamin K antagonist oral anticoagulants. METHODS AND RESULTS Using primary care electronic health records from the United Kingdom we followed adults with NVAF and who started rivaroxaban (20 mg/day, N = 5338) or warfarin (N = 6314), excluding those with estimated glomerular filtration rate (eGFR) <50 ml/min/1.73m2, end-stage renal disease (ESRD) or no eGFR or serum creatinine (SCr) values recorded in the previous year. Outcomes were: doubling SCr levels, ≥30% decline in eGFR and progression to ESRD. We calculated adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for each outcome. Average eGFR slope was estimated using mixed model regression. After a mean follow-up 2.5 years, the number of incident cases of adverse renal events within the two cohorts was: doubling SCr (n = 322), ≥30% decline in eGFR (n = 1179), and progression to ESRD (n = 22). Adjusted HRs (95% CIs) for the renal outcomes among rivaroxaban vs. warfarin users were: doubling SCr, 0.63 (0.49-0.81); ≥30% decline in eGFR, 0.76 (0.67-0.86); ESRD, 0.77 (0.29-2.04). Similar results were observed among patients with diabetes or heart failure. Estimated mean decline in renal function over the study period was 2.03 ml/min/1.73 m2/year among warfarin users and 1.65 ml/min/1.73 m2/year among rivaroxaban users (p = 0.03). CONCLUSIONS We found clear evidence that patients with NVAF, preserved renal function at baseline and treated with rivaroxaban had a markedly reduced risk and rate of renal decline compared with those treated with warfarin.
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Affiliation(s)
- Antonio González Pérez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain; Andalusian Bioinformatics Research Centre (CAEBi), Seville, Spain; Pharmacoepidemiology Research Group, Institute for Health Research (IRYCIS), Madrid, Spain.
| | | | - María E Sáez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain; Andalusian Bioinformatics Research Centre (CAEBi), Seville, Spain
| | - Gunnar Brobert
- Integrated Evidence Generation, Bayer AB, Stockholm, Sweden.
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21
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Kumar N, Xu H, Garg N, Pandey A, Matsouaka RA, Field ME, Turakhia MP, Piccini JP, Lewis WR, Fonarow GC. Patient characteristics, care patterns, and outcomes of atrial fibrillation associated hospitalizations in patients with chronic kidney disease and end-stage renal disease. Am Heart J 2021; 242:45-60. [PMID: 34216572 DOI: 10.1016/j.ahj.2021.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 06/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chronic Kidney Disease (CKD) and end-stage renal disease (ESRD) are associated with poor outcomes in patients with cardiovascular disease. There is a paucity of contemporary data on in-hospital outcomes and care patterns of atrial fibrillation (AF) associated hospitalizations CKD and ESRD. METHODS Outcomes and care patterns were evaluated in GWTG-AFIB database (Jan 2013-Dec 2018), including in-hospital mortality, use of a rhythm control strategy, and oral anticoagulation (OAC) prescription at discharge among eligible patients. Generalized logistic regression models with generalized estimating equations were used to ascertain differences in outcomes. Hospital-level variation in OAC prescription and rhythm control was also evaluated. RESULTS Among 50,154 patients from 105 hospitals the median age was 70 years (interquartile range 61-79) and 47.3% were women. The prevalence of CKD was 36.0% while that of ESRD was 1.6%. Among eligible patients, discharge OAC prescription rates were 93.6% for CKD and 89.1% for ESRD. After adjustment, CKD and ESRD were associated with higher in-hospital mortality (odds ratio [OR] 3.08, 95% confidence interval [CI] 1.57-6.03 for ESRD and OR 2.02, 95% CI 1.52-2.67 for CKD), lower odds of OAC prescription at discharge (OR 0.59, 95% CI 0.44-0.79 for ESRD and OR 0.84, 95% CI 0.75-0.94 for CKD) compared with normal renal function. CKD was associated with lower utilization of rhythm control strategy (OR 0.92, 95% CI 0.87-0.98) with no significant difference between ESRD and normal renal function (OR 1.32, 95% CI 0.79-1.11). There was large hospital-level variation in OAC prescription at discharge (MOR 2.34, 95% CI 2.05-2.76) and utilization of a rhythm control strategy (MOR 2.69, 95% CI 2.34-3.21). CONCLUSIONS CKD/ESRD is associated with higher in-hospital mortality, less frequent rhythm control, and less OAC prescription among patients hospitalized for AF. There is wide hospital-level variation in utilization of a rhythm control strategy and OAC prescription at discharge highlighting potential opportunities to improve care and outcomes for these patients, and better define standards of care in this patient population.
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22
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Chronic kidney disease and risks of adverse clinical events in patients with atrial fibrillation. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2021; 18:867-876. [PMID: 34908924 PMCID: PMC8648544 DOI: 10.11909/j.issn.1671-5411.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is highly prevalent in patients with atrial fibrillation (AF). However, the association between CKD and clinical consequences in AF patients is still under debate. METHODS We included 19,079 nonvalvular AF patients with available estimated glomerular filtration rate (eGFR) values in the Chinese Atrial Fibrillation Registry from 2011 to 2018. Patients were classified into no CKD (eGFR ≥ 90 mL/min per 1.73 m2), mild CKD (60 ≤ eGFR < 90 mL/min per 1.73 m 2), moderate CKD (30 ≤ eGFR < 60 mL/min per 1.73 m 2), and severe CKD (eGFR < 30 mL/min per 1.73 m 2) groups. The risks of thromboembolism, major bleeding, and cardiovascular mortality were estimated with Fine-Gray regression analysis according to CKD status. Cox regression was performed to assess the risk of all-cause mortality associated with CKD. RESULTS Over a mean follow-up of 4.1 ± 1.9 years, there were 985 thromboembolic events, 414 major bleeding events, 956 cardiovascular deaths, and 1,786 all-cause deaths. After multivariate adjustment, CKD was not an independent risk factor of thromboembolic events. As compared to patients with no CKD, those with mild CKD, moderate CKD, and severe CKD had a 45%, 47%, and 133% higher risk of major bleeding, respectively. There was a graded increased risk of cardiovascular mortality associated with CKD status compared with no CKD group: adjusted hazard ratio [HR] was 1.34 (95% CI: 1.07-1.68,P = 0.011) for mild CKD group, 2.17 (95% CI: 1.67-2.81,P < 0.0001) for moderate CKD group, and 2.95 (95% CI: 1.97-4.41, P < 0.0001) for severe CKD group, respectively. Risk of all-cause mortality also increased among patients with moderate or severe CKD. CONCLUSIONS CKD status was independently associated with progressively higher risks of major bleeding and mortality, but didn't seem to be an independent predictor of thromboembolism in AF patients.
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23
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Deguchi I, Osada T, Arai N, Takahashi S. Differences in oral anticoagulant prescriptions between specialists and non-specialists in patients with cardioembolic stroke caused by non-valvular atrial fibrillation. Heart Vessels 2021; 37:867-874. [PMID: 34797401 DOI: 10.1007/s00380-021-01984-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 11/05/2021] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation (AF) is a common disease encountered in daily practice; however, few patients with AF received oral anticoagulant (OAC) therapy. This study focused on differences in OAC prescriptions and influencing factors between specialists (neurological and cardiovascular) and non-specialists. A retrospective comparative analysis was conducted on 480 patients with acute cardioembolic stroke caused by non-valvular AF who were admitted to our hospital between January 1, 2015, and December 31, 2020. All patients had visited our hospital or other hospitals for their underlying diseases. Overall, 232 (specialist group SG) and 248 patients (non-specialist group NSG) were examined by specialists and non-specialists, respectively. The NSG had a significantly lower percentage of OAC prescriptions on admission than the SG (P < 0.01), even after propensity score matching. Factors influencing OAC prescription in the SG were age, hypertension, paroxysmal AF, dementia, CHADS2 score, and antiplatelet drug use, while those in the NSG were a history of cerebral infarction, paroxysmal AF, dementia, and antiplatelet drug use [SG: age, odds ratio (OR) 0.919, 95% confidence interval (CI) 0.865-0.976; hypertension, OR 0.266, 95% CI 0.099-0.713; paroxysmal AF, OR 0.189, 95% CI 0.055-0.658; dementia, OR 0.253, 95% CI 0.085-0.758; CHADS2 score, OR 2.833, 95% CI 1.682-4.942; and antiplatelet drug use, OR 0.072, 95% CI 0.025-0.206; NSG: cerebral infarction, OR 5.940, 95% CI 1.581-22.309; paroxysmal AF, OR 0.077, 95% CI 0.010-0.623; dementia, OR 0.077, 95% CI 0.014-0.438; and antiplatelet drug use, OR 0.024, 95% CI 0.004-0.152]. In conclusion, the OAC prescription rate was higher in patients with non-valvular AF whose family physicians were specialists at the time of cerebral infarction onset. In addition, in the SG, advanced age and hypertension were associated with not prescribing OAC, whereas a higher CHADS2 score was associated with the prescription of OACs. In the NSG, a history of cerebral infarction was associated with the prescription of OACs. Further, paroxysmal AF, antiplatelet drug use, and dementia were associated with non-OAC therapy in both the groups.
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Affiliation(s)
- Ichiro Deguchi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan.
| | - Takashi Osada
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Noriko Arai
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Shinichi Takahashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
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24
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Leonte RM, Lucaci LV, Vlad CE, Florea A, Florea L. Atrial fibrillation, end-stage renal disease and hemorrhagic pleural-pericarditis. Arch Clin Cases 2021; 6:103-108. [PMID: 34754917 PMCID: PMC8565713 DOI: 10.22551/2019.25.0604.10162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Pericarditis is the most common pericardial disease found in clinical practice, with an incidence of acute pericarditis reported in 27.7 cases per 100,000 subjects per year. Hemodialysis in end stage renal disease (ESRD) is associated with frequent cardiovascular modifications, mostly because of the highly fluctuating levels of potassium, magnesium, ionized calcium, sodium and volume status. The risk of arrhythmias is increased and chronic atrial fibrillation (AF) can be found among approximately 14% of patients. The renal disease combined with arrhythmias increases the risk of systemic thromboembolism but also of bleeding events. Here we present the case of a male patient, with ESRD, recently diagnosed with intradialytic paroxysmal AF for which oral anticoagulation therapy is initiated, but it’s early complicated with hemorrhagic pleural-pericarditis.
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Affiliation(s)
- Raluca-Mihaela Leonte
- Department of Cardiology, "Prof. Dr. George I.M. Georgescu" Institute of Cardiovascular Diseases, Iasi, Romania
| | - Laurențiu Vladimir Lucaci
- Department of Cardiology, "Prof. Dr. George I.M. Georgescu" Institute of Cardiovascular Diseases, Iasi, Romania.,"Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Cristiana Elena Vlad
- Department of Internal Medicine, "Dr. C.I. Parhon", Iasi, Romania.,"Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Andreea Florea
- "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | - Laura Florea
- Department of Internal Medicine, "Dr. C.I. Parhon", Iasi, Romania.,"Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
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25
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Gach O, Pierard LA. Atrial fibrillation, diabetes and anticoagulation with direct oral anticoagulants: time to reconsider duration of the disease to evaluate the bleeding risk? Acta Cardiol 2021; 76:461-463. [PMID: 33435835 DOI: 10.1080/00015385.2020.1870194] [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: 10/22/2022]
Abstract
Atrial fibrillation and diabetes: time to reconsider duration of the disease to evaluate the bleeding risk? Impact of diabetes status in patients suffering of non-valvular atrial fibrillation requiring anticoagulation have been analysed previously and risk/benefit balance of NOACs have been confirmed in these patients. The implication of that pathology in the evaluation of the thrombotic risk is discussed but more importantly bleeding risk in this growing population is analysed, perhaps neglected until now.
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Affiliation(s)
- Olivier Gach
- Université de Liège. Service de Cardiologie, CHC MontLégia, Liège, Belgium
| | - Luc A. Pierard
- Faculté de Médecine. Département des sciences cliniques, Université de Liège, Liège, Belgium
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26
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Piazza G, Hurwitz S, Galvin CE, Harrigan L, Baklla S, Hohlfelder B, Carroll B, Landman AB, Emani S, Goldhaber SZ. Alert-based computerized decision support for high-risk hospitalized patients with atrial fibrillation not prescribed anticoagulation: a randomized, controlled trial (AF-ALERT). Eur Heart J 2021; 41:1086-1096. [PMID: 31228189 DOI: 10.1093/eurheartj/ehz385] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/25/2019] [Accepted: 05/20/2019] [Indexed: 12/28/2022] Open
Abstract
AIMS Despite widely available risk stratification tools, safe and effective anticoagulant options, and guideline recommendations, anticoagulation for stroke prevention in atrial fibrillation (AF) is underprescribed. We created and evaluated an alert-based computerized decision support (CDS) strategy to increase anticoagulation prescription in hospitalized AF patients at high risk for stroke. METHODS AND RESULTS We enrolled 458 patients (CHA2DS2-VASc score ≥1) with AF who were not prescribed anticoagulant therapy and were hospitalized at Brigham and Women's Hospital. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) vs. control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription. The CDS tool assigned 248 patients to the alert group and 210 to the control group. Patients in the alert group were more likely to be prescribed anticoagulation during the hospitalization (25.8% vs. 9.5%, P < 0.0001), at discharge (23.8% vs. 12.9%, P = 0.003), and at 90 days (27.7% vs. 17.1%, P = 0.007). The alert reduced the odds of a composite outcome of death, myocardial infarction (MI), cerebrovascular event, and systemic embolic event at 90 days [11.3% vs. 21.9%, P = 0.002; odds ratio (OR) 0.45; 95% confidence interval (CI) 0.27-0.76]. The alert reduced the odds of MI at 90 days by 87% (1.2% vs. 8.6%, P = 0.0002; OR 0.13; 95% CI 0.04-0.45) and cerebrovascular events or systemic embolism at 90 days by 88% (0% vs. 2.4%, P = 0.02; OR 0.12; 95% CI 0.0-0.91). CONCLUSION An alert-based CDS strategy increased anticoagulation in high-risk hospitalized AF patients and reduced major adverse cardiovascular events, including MI and stroke. CLINICALTRIALS.GOV IDENTIFIER NCT02339493.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Shelley Hurwitz
- Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA
| | - Claire E Galvin
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Lindsay Harrigan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Sofia Baklla
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Benjamin Hohlfelder
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195, USA
| | - Brett Carroll
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave., Boston, MA 02215, USA
| | - Adam B Landman
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Srinivas Emani
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
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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.
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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.
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Yasaka M, Yamashita T, Akao M, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Shimizu W, Tsutsui H, Toyoda K, Hirayama A, Yamaguchi T, Teramukai S, Kimura T, Kaburagi J, Takita A, Inoue H. Background characteristics and anticoagulant usage patterns of elderly non-valvular atrial fibrillation patients in the ANAFIE registry: a prospective, multicentre, observational cohort study in Japan. BMJ Open 2021; 11:e044501. [PMID: 34006033 PMCID: PMC7942257 DOI: 10.1136/bmjopen-2020-044501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To explore anticoagulant usage patterns stratified by stroke and bleeding risk in elderly patients with non-valvular atrial fibrillation (NVAF). DESIGN Prospective, multicentre, observational cohort study. SETTING The real-world All Nippon AF In the Elderly (ANAFIE) registry. PARTICIPANTS Japanese patients aged ≥75 years with NVAF (n=32 726). OUTCOME MEASURES The distribution of stroke and bleeding risk scores, and the selection of anticoagulant regimen for patients at high stroke and bleeding risk. RESULTS Overall, 18 185 (55.6%) patients had a high risk of stroke (CHADS2 score ≥3). Of these, 12 561 (38.4% of the total ANAFIE population) had a low bleeding risk (HAS-BLED ≤2) and 5624 (17.2%) had a high bleeding risk (HAS-BLED ≥3). Significant differences were noted between the high versus low bleeding risk groups in sex, height, weight, systolic blood pressure and rates of abnormality of lipid metabolism, gastrointestinal disease, cerebrovascular disorders, chronic kidney disease, angina pectoris, respiratory disease, primary malignant tumour, dementia and fall history within the past year (all p<0.0001). Patients with high stroke and bleeding risks had a lower anticoagulant usage rate versus the low bleeding risk group, and 8.7% and 5.8%, respectively, were not receiving any anticoagulant (p<0.0001). Patients in the high bleeding risk group had a higher usage of warfarin versus the low bleeding risk group (p<0.0001); more patients (14.0%) in the high bleeding risk group receiving warfarin had time in the therapeutic range <40%, versus those in the low bleeding risk group (11.6%, p=0.0146). Direct-acting oral anticoagulants (DOACs) were used less in the high bleeding risk group, without notable differences in the DOAC dose distribution between the two groups. CONCLUSIONS In elderly NVAF patients at high stroke risk, significant demographic and clinical differences were observed according to bleeding risk. Administration of low-dose DOACs was frequent, but the dose distribution was unaffected by bleeding risk. TRIAL REGISTRATION NUMBER UMIN000024006 (http://www.umin.ac.jp/).
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Affiliation(s)
- Masahiro Yasaka
- Department of Cerebrovascular and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Yukihiro Koretsune
- Institute for Clinical Research, National Hospital Organization, Osaka National Hospital, Osaka, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
| | - Kazunori Toyoda
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | | | | | - Satoshi Teramukai
- Department of Biostatistics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuya Kimura
- Medical Science Department, Daiichi Sankyo Co., Ltd, Tokyo, Japan
| | | | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd, Tokyo, Japan
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Kozieł M, Simovic S, Pavlovic N, Nedeljkovic M, Kocijancic A, Paparisto V, Music L, Trendafilova E, Dan AR, Manola S, Kusljugic Z, Dan G, Lip GYH, Potpara TS. Treatment implications of renal disease in patients with atrial fibrillation: The BALKAN-AF survey. J Arrhythm 2020; 36:863-873. [PMID: 33024464 PMCID: PMC7532276 DOI: 10.1002/joa3.12404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/10/2020] [Accepted: 06/24/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) often co-exists with renal function (RF) impairment. We investigated the characteristics and management of AF patients across creatinine clearance strata and potential changes in the use of nonvitamin K oral anticoagulants (NOAC) according to different equations for estimation of RF. METHODS In this post hoc analysis of the BALKAN-AF survey, patients were classified according to RF (Cockcroft-Gault formula) as: preserved/mildly depressed RF (P-RF) ≥50 mL/min, moderately depressed RF (MD-RF) 30-49 mL/min, and severely depressed RF (SD-RF) <30 mL/min. RESULTS Of 2712 enrolled patients, 2062 (76.0%) had data on RF. Patients with SD-RF and MD-RF were older, had higher mean value of European Heart Rhythm Association score, stroke and bleeding risk scores, and more comorbidities than patients with P-RF (all P < .05). They received oral anticoagulants (OAC), AF catheter ablation, and electrical cardioversion less often than those with P-RF (all P < .05). Rate control, no OAC, single-antiplatelet therapy (SAPT) alone, and loop diuretics were more prevalent in patients with SD-RF and MD-RF than in subjects with P-RF (all P < .005). An important change in NOAC therapy could appear in <1% of patients (Modification of Diet in Renal Disease formula) and in <1% of patients (Chronic Kidney Disease Epidemiology Collaboration group formula). CONCLUSIONS Patients with SD-RF and MD-RF were older, more symptomatic, had higher stroke and bleeding risk and more comorbidities than those with P-RF. They were less likely to receive OAC and more likely to use rate control strategy, SAPT alone, and no OAC than subjects with P-RF.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
- 1st Department of Cardiology and AngiologySilesian Centre for Heart DiseasesZabrzePoland
| | - Stefan Simovic
- Cardiology ClinicUniversity Clinical Center of KragujevacKragujevacSerbia
| | | | - Milan Nedeljkovic
- Cardiology ClinicClinical Center of SerbiaBelgradeSerbia
- School of MedicineBelgrade UniversityBelgradeSerbia
| | | | - Vilma Paparisto
- Clinic of CardiologyUniversity Hospital Center Mother TheresaTiranaAlbania
| | - Ljilja Music
- Cardiology ClinicUniversity Clinical Center of MontenegroUniversity of PodgoricaMedical FacultyPodgoricaMontenegro
| | | | - Anca Rodica Dan
- Cardiology DepartmentColentina University HospitalBucharestRomania
| | - Sime Manola
- Clinical Center Sestre MilosrdniceZagrebCroatia
| | - Zumreta Kusljugic
- Cardiology DepartmentClinic of Internal MedicineMedical FacultyUniversity Clinical Center TuzlaTuzlaBosnia and Herzegovina
| | - Gheorghe‐Andrei Dan
- Medicine University "Carol Davila"Colentina University HospitalBucharestRomania
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
- 1st Department of Cardiology and AngiologySilesian Centre for Heart DiseasesZabrzePoland
- School of MedicineBelgrade UniversityBelgradeSerbia
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Tatjana S. Potpara
- Cardiology ClinicClinical Center of SerbiaBelgradeSerbia
- School of MedicineBelgrade UniversityBelgradeSerbia
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30
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Goto S, Haas S, Ageno W, Goldhaber SZ, Turpie AGG, Weitz JI, Angchaisuksiri P, Nielsen JD, Kayani G, Farjat A, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Assessment of Outcomes Among Patients With Venous Thromboembolism With and Without Chronic Kidney Disease. JAMA Netw Open 2020; 3:e2022886. [PMID: 33112399 PMCID: PMC7593818 DOI: 10.1001/jamanetworkopen.2020.22886] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Patients with venous thromboembolism (VTE) and concomitant chronic kidney disease (CKD) have been reported to have a higher risk of thrombosis and major bleeding complications compared with patients without concomitant CKD. The use of anticoagulation therapy is challenging, as many anticoagulant medications are excreted by the kidney. Large-scale data are needed to clarify the impact of CKD for anticoagulant treatment strategies and clinical outcomes of patients with VTE. OBJECTIVE To compare clinical characteristics, treatment patterns, and 12-month outcomes among patients with VTE and concomitant moderate to severe CKD (stages 3-5) vs patients with VTE and mild to no CKD (stages 1-2) in a contemporary international registry. DESIGN, SETTING, AND PARTICIPANTS The Global Anticoagulant Registry in the Field-Venous Thromboembolism (GARFIELD-VTE) study is a prospective noninterventional investigation of real-world treatment practices. A total of 10 684 patients from 415 sites in 28 countries were enrolled in the GARFIELD-VTE between May 2014 and January 2017. This cohort study included 8979 patients (6924 patients with mild to no CKD and 2055 patients with moderate to severe CKD) who had objectively confirmed VTE within 30 days before entry in the registry. Chronic kidney disease stages were defined by estimated glomerular filtration rates. Data were extracted from the study database on December 8, 2018, and analyzed between May 1, 2019, and July 30, 2020. EXPOSURE Moderate to severe CKD vs mild to no CKD. MAIN OUTCOMES AND MEASURES The primary outcomes were all-cause mortality, recurrent VTE, and major bleeding. Event rates and 95% CIs were calculated and expressed per 100 person-years. Hazard ratios (HRs) were estimated with Cox proportional hazards regression models and adjusted for relevant confounding variables. All-cause mortality was considered a competing risk for other clinical outcomes in the estimation of cumulative incidences. RESULTS Of the 10 684 patients with objectively confirmed VTE, serum creatinine data were available for 8979 patients (84.0%). Of those, 4432 patients (49.4%) were female and 5912 patients (65.8%) were White; 6924 patients (77.1%; median age, 57 years; interquartile range [IQR], 44-69 years) were classified as having mild to no CKD, and 2055 patients (22.9%; median age, 70 years; IQR, 59-78 years) were classified as having moderate to severe CKD. Calculations using the equation from the Modification of Diet in Renal Disease study indicated that, among the 6924 patients with mild to no CKD, 2991 patients had stage 1 CKD, and 3933 patients had stage 2 CKD; among the 2055 patients with moderate to severe CKD, 1650 patients had stage 3 CKD, 190 patients had stage 4 CKD, and 215 patients had stage 5 CKD. The distribution of VTE presentation was comparable between groups. In total, 1171 patients (57.0%) with moderate to severe CKD and 4079 patients (58.9%) with mild to no CKD presented with deep vein thrombosis alone, 547 patients (26.6%) with moderate to severe CKD and 1723 patients (24.9%) with mild to no CKD presented with pulmonary embolism alone, and 337 patients (16.4%) with moderate to severe CKD and 1122 patients (16.2%) with mild to no CKD presented with both pulmonary embolism and deep vein thrombosis. Compared with patients with mild to no CKD, patients with moderate to severe CKD were more likely to be female (3259 women [47.1%] vs 1173 women [57.1%]) and older than 65 years (2313 patients [33.4%] vs 1278 patients [62.2%]). At baseline, the receipt of parenteral therapy alone was comparable between the 2 groups (355 patients [17.3%] with moderate to severe CKD vs 1253 patients [18.1%] with mild to no CKD). Patients with moderate to severe CKD compared with those with mild to no CKD were less likely to be receiving direct oral anticoagulant therapy, either alone (557 patients [27.1%] vs 2139 patients [30.9%]) or in combination with parenteral therapy (319 patients [15.5%] vs 1239 patients [17.9%]). Patients with moderate to severe CKD had a higher risk of all-cause mortality (adjusted hazard ratio [aHR], 1.44; 95% CI, 1.21-1.73), major bleeding (aHR, 1.40; 95% CI, 1.03-1.90), and recurrent VTE (aHR, 1.40; 95% CI, 1.10-1.77) than patients with mild to no CKD. CONCLUSIONS AND RELEVANCE In this study of patients with VTE, the presence of moderate to severe CKD was associated with increases in the risk of death, VTE recurrence, and major bleeding compared with the presence of mild to no CKD.
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Affiliation(s)
- Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Sylvia Haas
- Technical University of Munich, Munich, Germany
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | | | - Jeffrey I. Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
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31
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Darius H. Vorhofflimmern und Antikoagulation im Alter. AKTUELLE KARDIOLOGIE 2020. [DOI: 10.1055/a-1242-9781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungVorhofflimmern und auch Vorhofflattern sind aufgrund der mechanischen Stase im Vorhof mit einer hohen Thrombembolierate, also Schlaganfällen oder systemischen Thrombembolien, assoziiert. Die orale Antikoagulation reduziert die Rate der thrombembolischen Ereignisse um ca. ⅔, bei Einsatz von NOAC sogar noch etwas mehr. Bei älteren und alten Patienten ist das thrombembolische Risiko deutlich erhöht, insbesondere wenn Risikofaktoren wie arterielle Hypertonie, Herzinsuffizienz oder Niereninsuffizienz vorhanden sind. Ältere und alte Patienten profitieren von einer Antikoagulation aufgrund des höheren absoluten Risikos deutlich mehr als jüngere Patienten, obwohl sie auch ein erhöhtes Blutungsrisiko haben. Das Blutungsrisiko kann durch Behandlung modifizierbarer Risikofaktoren, Überprüfung bzw. Modifikation der Komedikation und patientenorientierte Dosierung der NOAC unter Berücksichtigung der Nierenfunktion deutlich reduziert werden. Dadurch können auch ältere und alte Patienten von einer effektiven Antikoagulation profitieren und Schlaganfälle verhindert werden.
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Affiliation(s)
- Harald Darius
- Kardiologie, Angiologie, Nephrologie und konservative Intensivmedizin, Vivantes Klinikum Neukölln, Berlin, Deutschland
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32
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Ding WY, Gupta D, Wong CF, Lip GYH. Pathophysiology of atrial fibrillation and chronic kidney disease. Cardiovasc Res 2020; 117:1046-1059. [PMID: 32871005 DOI: 10.1093/cvr/cvaa258] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/28/2020] [Accepted: 08/25/2020] [Indexed: 01/06/2023] Open
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are closely related conditions with shared risk factors. The growing prevalence of both AF and CKD indicates that more patients will suffer from concurrent conditions. There are various complex interlinking mechanisms with important implications for the management of these patients. Furthermore, there is uncertainty regarding the use of oral anticoagulation (OAC) in AF and CKD that is reflected by a lack of consensus between international guidelines. Therefore, the importance of understanding the implications of co-existing AF and CKD should not be underestimated. In this review, we discuss the pathophysiology and association between AF and CKD, including the underlying mechanisms, risk of thrombo-embolic and bleeding complications, influence on stroke management, and evidence surrounding the use of OAC for stroke prevention.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Christopher F Wong
- Department of Renal Medicine, Liverpool University Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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33
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Bassand JP, Apenteng PN, Atar D, Camm AJ, Cools F, Corbalan R, Fitzmaurice DA, Fox KA, Goto S, Haas S, Hacke W, Jerjes-Sanchez C, Koretsune Y, Heuzey JYL, Sawhney JP, Oh S, Stępińska J, Cate VT, Verheugt FW, Kayani G, Pieper KS, Kakkar AK, Garfield-Af Investigators FT. GARFIELD-AF: a worldwide prospective registry of patients with atrial fibrillation at risk of stroke. Future Cardiol 2020; 17:19-38. [PMID: 32696663 DOI: 10.2217/fca-2020-0014] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD-AF) examined real-world practice in a total of 57,149 (5069 retrospective, 52,080 prospective) patients with newly diagnosed AF at risk of stroke/systemic embolism, enrolled at over 1000 centers in 35 countries. It aimed to capture data on AF burden, patients' clinical profile, patterns of clinical practice and antithrombotic management, focusing on stroke/systemic embolism prevention, uptake of new oral anticoagulants, impact on death and bleeding. GARFIELD-AF set new standards for quality of data collection and analysis. A total of 36 peer-reviewed articles were already published and 73 abstracts presented at international congresses, covering treatment strategies, geographical variations in baseline risk and therapies, adverse outcomes and common comorbidities such as heart failure. A risk prediction tool as well as innovative observational studies and artificial intelligence methodologies are currently being developed by GARFIELD-AF researchers. Clinical Trial Registration: NCT01090362 (ClinicalTrials.gov).
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Affiliation(s)
- Jean-Pierre Bassand
- Department of Cardiology, University of Besançon, Besançon 25000, France.,Department of Clinical Research, Thrombosis Research Institute, London SW3 6LR, UK
| | | | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevaal, Oslo PO Box 4956, Norway.,Institute of Clinical Science, University of Oslo, Oslo PO Box 4956, Norway
| | - A John Camm
- Molecular & Clinical Sciences Research Institute, St George's University of London, London SW17 0RE, UK
| | - Frank Cools
- Department of Cardiology, AZ Klina, Brasschaat 100, 2930, Belgium
| | - Ramon Corbalan
- Department of Cardiology, Catholic University, Santiago 8330024, Chile
| | | | - Keith Aa Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Shinya Goto
- Department of Medicine(Cardiology), Tokai University School of Medicine, Kanagawa 259-1143, Japan
| | - Sylvia Haas
- Department of Medicine, Formerly Technical University of Munich, Munich 80333, Germany
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg 69120, Germany
| | | | - Yukihiro Koretsune
- Institute for Clinical Research, Osaka National Hospital, Osaka 540-0006, Japan
| | - Jean-Yves Le Heuzey
- Department of Arrhythmia, European Hospital Georges Pompidou, René Descartes University, Paris 75015, France
| | | | - Seil Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 110-799, Republic of Korea
| | - Janina Stępińska
- Intensive Cardiac Therapy Clinic, Institute of Cardiology, Warsaw 04-628, Poland
| | - Vincent Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht 6200, The Netherlands
| | - Freek Wa Verheugt
- Depertment of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam NL-1091-AC, The Netherlands
| | - Gloria Kayani
- Department of Clinical Research, Thrombosis Research Institute, London SW3 6LR, UK
| | - Karen S Pieper
- Department of Clinical Research, Thrombosis Research Institute, London SW3 6LR, UK
| | - Ajay K Kakkar
- Department of Clinical Research, Thrombosis Research Institute, London SW3 6LR, UK.,Department of Surgery, University College London, London WC1E 6BT, UK
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34
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Relationship between the Renal Function and Adverse Clinical Events in Patients with Atrial Fibrillation: A Japanese Multicenter Registry Substudy. J Clin Med 2020; 9:jcm9010167. [PMID: 31936260 PMCID: PMC7019418 DOI: 10.3390/jcm9010167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist, but the real-world data after approval of direct oral anticoagulants (DOACs) are still lacking in Japan. We investigated the association of the baseline renal function and adverse clinical events and risk of adverse clinical events with DOACs compared to warfarin for each renal functional level in Japanese AF patients. METHODS The present substudy was based on the SAKURA AF Registry, a Japanese multicenter observational registry (median follow-up period: 39 months). The creatinine clearance (CrCl) values were estimated by the Cockcroft-Gault formula, and divided into normal renal function, and mild and moderate-severe CKD (CrCl ≥ 80, 50-79, <50 mL/min). RESULTS In the SAKURA AF Registry, the baseline CrCl data were available for 3242 patients (52% for DOAC and 48% for warfarin user). The relative risk of adverse clinical events was significantly higher in the patients with a CrCl < 50 mL/min as compared to those with a CrCl ≥ 80 mL/min (adjusted HRs: 2.53 for death, 2.53 for cardiovascular [CV] events, 2.13 for strokes, and 1.83 for major bleeding). Risks of all adverse clinical events were statistically even between DOAC and warfarin users for each renal function level. CONCLUSION Moderate-severe CKD was associated with a higher mortality, CV events, strokes, and major bleeding than normal renal function. The safety and effectiveness of DOACs over warfarin were similar for each renal function level. By a worsening renal function, the incidence of adverse clinical events increased, especially deaths and CV events as compared to strokes and major bleeding.
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35
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Zeymer U, Bonnemeier H, Wanner C. [Anticoagulation in patients with non-valvular atrial fibrillation (nvAF) and chronic kidney disease (CKD)]. Dtsch Med Wochenschr 2019; 144:1642-1649. [PMID: 31752037 DOI: 10.1055/a-1008-5548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Due to the associated risk of stroke, non-valvular atrial fibrillation (nvAF) is a major indication for oral anticoagulation. Many patients suffer from chronic kidney disease (CKD), which increases the risk for stroke and for bleeding. Vitamin K antagonists (VKA) receive only cautious recommendations in guidelines for patients with CKD and nvVHF due to heterogeneous study results; their summaries of product characteristics contain contraindications for patients with manifest CKD. Novel oral anticoagulants (NOACs) have been investigated and are approved in CKD patients with a creatinine clearance (CrCl) ≥ 25 or 30 ml/min, factor Xa inhibitors can be used also if CrCl is > 15 ml/min. NOACs show an advantageous benefit-risk profile compared to VKA in reducing stroke, other thromboembolic events and death on the one hand and occurrence of bleedings on the other, and are recommended by the current ESC guidelines.
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Affiliation(s)
- Uwe Zeymer
- Medizinische Klinik B, Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin; Klinikum der Stadt Ludwigshafen am Rhein
| | - Hendrik Bonnemeier
- Klinik für Innere Medizin III, Kardiologie, Angiologie, Intensivmedizin; Universitätsklinikum Schleswig-Holstein, Kiel
| | - Christoph Wanner
- Medizinische Klinik I, Nephrologie; Universitätsklinikum Würzburg
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36
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Ramagopalan SV, Stamp E, Sammon CJ, Besford M, Carroll R, Mehmud F, Alikhan R. Renal function and oral anticoagulant treatment of incident non-valvular atrial fibrillation: a retrospective study. Future Cardiol 2019; 15:301-309. [PMID: 31140872 DOI: 10.2217/fca-2019-0012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To describe the renal function of individuals newly diagnosed with non-valvular atrial fibrillation in England, and describe how oral anticoagulant (OAC) treatment varies according to renal function. Patients & methods: We identified a cohort of individuals with non-valvular atrial fibrillation (n = 18,419) and described their renal function at diagnosis and the prevalence of OAC treatment initiation by renal function. Results: 79% of individuals had some evidence of renal dysfunction with 12% having a glomerular filtration rate <30 ml/min/1.73 m2. OAC treatment initiation in the 6 months following diagnosis was lower in individuals with severe renal dysfunction than in those with normal renal function. Conclusion: The high prevalence of renal dysfunction and low OAC treatment prevalence highlights the need for additional evidence regarding OACs in individuals with severe renal dysfunction.
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Affiliation(s)
- Sreeram V Ramagopalan
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, UB8 1DH, UK
| | | | | | | | - Robert Carroll
- Centre for Observational Research & Data Sciences, Bristol-Myers Squibb, UB8 1DH, UK
| | | | - Raza Alikhan
- Department of Haematology, University Hospital of Wales, Cardiff & Vale University Health Board, Cardiff, CF14 4XW, UK
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Luani B, Genz C, Herold J, Mitrasch A, Mitusch J, Wiemer M, Schmeißer A, Braun-Dullaeus RC, Rauwolf T. Cerebrovascular events, bleeding complications and device related thrombi in atrial fibrillation patients with chronic kidney disease and left atrial appendage closure with the WATCHMAN™ device. BMC Cardiovasc Disord 2019; 19:112. [PMID: 31092201 PMCID: PMC6518765 DOI: 10.1186/s12872-019-1097-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 05/03/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Impaired renal function increases the bleeding risk, leading to a conservative prescription and frequent discontinuation of oral anticoagulation in atrial fibrillation patients with chronic kidney disease (CKD). Interventional left atrial appendage closure (LAAC) might be an alternative therapeutic strategy for these patients. METHODS We aimed to prospectively assess cerebrovascular (CE) and bleeding events, as well as peri-procedural and long-term complications in a cohort of consecutive patients undergoing interventional LAAC using the WATCHMAN™ device, with focus on CKD patients. RESULTS One hundred and eighty-nine consecutive patients undergoing interventional LAAC were included in this analysis; 171 (90.5%) patients had a reduced estimated glomerular filtration rate (eGFR; patients for each CKD stage: II = 66; IIIa = 32; IIIb = 43; IV = 18; V = 12). During a follow-up of 310 patient years three (1.0%) patients suffered a CE (two strokes, one transitory ischemic attack) and five (1.6%) other ones a bleeding complication. The observed stroke rate was more than two-thirds and the bleeding risk more than half lower than expected. Device related thrombi (DRT) were detected in twelve (6.5%) patients; women had significantly more DRT than men (12.5% vs. 2.6%; p = 0.009). Patients with an eGFR< 30 ml/min/1.73m2 showed a trend to a higher DRT rate as compared to the opposite group (13.3% vs. 5.1%; p = 0.10). Thrombus resolved with temporary oral anticoagulation therapy in ten patients without sequelae; thrombus consolidation was confirmed by serial TEE controls in the remaining two patients. CONCLUSIONS Atrial fibrillation patients with CKD have low CE and bleeding rates after LAAC with the WATCHMAN™ device. DRT risk is higher in female and patients with severe CKD. More frequent post-interventional TEE controls might be justified for early DRT detection and safe management of patients at high DRT risk. TRIAL REGISTRATION (German Clinical Trials Register ID: DRKS00 010768 ; Registration Date 07.07.2016).
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Affiliation(s)
- Blerim Luani
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Hans-Nolte-Str. 1, 32429 Minden, Germany
| | - Conrad Genz
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
| | - Joerg Herold
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
| | - Andreas Mitrasch
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
| | - Julius Mitusch
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
| | - Marcus Wiemer
- Department of Cardiology and Intensive Care Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Hans-Nolte-Str. 1, 32429 Minden, Germany
| | - Alexander Schmeißer
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
| | - Rüdiger C. Braun-Dullaeus
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
| | - Thomas Rauwolf
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr 44, 39120 Magdeburg, Germany
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Ding WY, Khan AA, Gupta D, Lip GYH. Short-Term Outcomes in Newly Diagnosed Atrial Fibrillation and Chronic Kidney Disease: How Important Is Ethnicity? J Am Heart Assoc 2019; 8:e011953. [PMID: 30717613 PMCID: PMC6405578 DOI: 10.1161/jaha.119.011953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
See Article by Goto et al.
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Affiliation(s)
- Wern Yew Ding
- 1 Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom
| | - Ahsan A Khan
- 1 Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom
| | - Dhiraj Gupta
- 1 Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom
| | - Gregory Y H Lip
- 1 Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.,2 Aalborg Thrombosis Research Unit Department of Clinical Medicine Aalborg University Aalborg Denmark
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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: 39] [Impact Index Per Article: 7.8] [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.
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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
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