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Atarashi H, Uchiyama S, Inoue H, Kitazono T, Yamashita T, Shimizu W, Ikeda T, Kamouchi M, Kaikita K, Fukuda K, Origasa H, Shimokawa H. Ischemic stroke, hemorrhage, and mortality in patients with non-valvular atrial fibrillation and renal dysfunction treated with rivaroxaban: sub-analysis of the EXPAND study. Heart Vessels 2021; 36:1410-1420. [PMID: 33728513 PMCID: PMC8332581 DOI: 10.1007/s00380-021-01810-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 02/19/2021] [Indexed: 11/30/2022]
Abstract
The EXPAND Study demonstrated the effectiveness and safety of rivaroxaban in patients with non-valvular atrial fibrillation (NVAF) in routine clinical practice in Japan. This sub-analysis was conducted to reveal the effectiveness and safety of rivaroxaban in Japanese NVAF patients according to baseline creatinine clearance (CrCl) levels and rivaroxaban doses in the EXPAND Study. We examined 6806 patients whose baseline CrCl data were available and classified them into 2 groups: normal renal function group with CrCl ≥ 50 mL/min (n = 5326, 78%) and renal dysfunction group with CrCl < 50 mL/min (n = 1480, 22%). In the normal renal function group, 1609 (30%) received 10 mg/day (under-dose), while in the renal dysfunction group, 108 (7%) received 15 mg/day (over-dose). In the normal renal function group, under-dose of rivaroxaban was associated with higher all-cause mortality, while in the renal dysfunction group, over-dose was associated with higher incidence of major bleeding. In contrast, the incidence of stroke or systemic embolism was not different between the 2 groups regardless of the dose of rivaroxaban. In the propensity score matched analysis to adjust the difference in characteristics according to doses of rivaroxaban, the incidences of clinical outcomes were comparable between the 2 dose groups in both renal function groups. These results indicate that the dose of rivaroxaban should be reduced depending on the renal function, considering the balance between risks of bleeding and ischemia.
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Affiliation(s)
- Hirotsugu Atarashi
- Minamihachioji Hospital, Koyasu-cho 3-18-12, Hachioji, Tokyo, 192-0904, Japan
| | - Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Akasaka 8-5-35, Minato-ku, Tokyo, 107-0052, Japan
| | - Hiroshi Inoue
- Saiseikai Toyama Hospital, Kusunoki 33-1, Toyama, 931-8533, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takeshi Yamashita
- Cardiovascular Institute Hospital, Nishiazabu 3-2-19, Minato-Ku, Tokyo, 106-0031, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, Sendagi 1-1-5, Bunkyo-ku, Tokyo, 113-8602, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Faculty of Medicine, Toho University, Omorinishi 5-21-16, Ota-ku, Tokyo, 143-8540, Japan
| | - Masahiro Kamouchi
- Department of Health Care Administration and Management, Center for Cohort Study, Kyushu University Graduate School of Medical Sciences, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 2-39-1, Kurokami Chuo-ku, Kumamoto, 860-8555, Japan
| | - Koji Fukuda
- Division of Heart Rhythm, International University of Health and Welfare Hospital, Iguchi 537-3, Nasushiobara, Japan
| | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine, Sugitani 2630, Toyama, 930-0194, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Seiryomachi 1-1, Aoba-ku, Sendai, 980-8574, Japan. .,International University of Health and Welfare, Kozunomori 4-3, Narita, 286-8686, Japan.
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Kodani E, Akao M. Atrial fibrillation and stroke prevention: state of the art-epidemiology and pathophysiology: new risk factors, concepts and controversies. Eur Heart J Suppl 2020; 22:O1-O13. [PMID: 33380940 PMCID: PMC7753870 DOI: 10.1093/eurheartj/suaa176] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Atrial fibrillation (AF) increases the risk of thromboembolism, and risk assessment for thromboembolism is necessary for the management of AF patients. CHADS2 and CHA2DS2-VASc scores have been adopted in international guidelines for AF management, but the significance of each risk factor included in these risk scores are sometimes controversial, and the performance of these scores is only modest. There are several other risk factors not included in the scores such as renal dysfunction, low body weight, type of AF (paroxysmal or non-paroxysmal) as well as echocardiographic parameters and blood biomarkers, and physicians should assess patients risk in an integrated manner.
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Affiliation(s)
- Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama-Nagayama Hospital, 1-7-1, Nagayama, Tama-shi, Tokyo 206-8512, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan
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Kodani E, Inoue H, Atarashi H, Tomita H, Okumura K, Yamashita T, Origasa H. Predictive ability of creatinine clearance versus estimated glomerular filtration rate for outcomes in patients with non-valvular atrial fibrillation: Subanalysis of the J-RHYTHM Registry. IJC HEART & VASCULATURE 2020; 29:100559. [PMID: 32566722 PMCID: PMC7298529 DOI: 10.1016/j.ijcha.2020.100559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Renal impairment is a risk factor for various adverse events, especially for death. In general, creatinine clearance (CrCl) is used for dose-adjustments of many drugs including oral anticoagulants, and estimated glomerular filtration rate (eGFR) is adopted for the diagnosis of chronic kidney disease. Predictive ability of CrCl versus eGFR for outcomes in patients with non-valvular atrial fibrillation (NVAF) remains controversial; therefore, this was compared using data from the J-RHYTHM Registry. METHODS Out of 7406 outpatients with NVAF from 158 institutions, 6004 (age, 69.7 ± 9.9 years; men, 71.2%) having data of CrCl (mL/min, by the Cockcroft-Gault formula), eGFR (mL/min/1.73 m2, by the equations of the Japanese Society of Nephrology), and body surface area (BSA) were analyzed. C-statistics (area under the receiver-operating characteristic curve) of CrCl and eGFR for events were compared by DeLong's test. RESULTS Thromboembolism, major hemorrhage, and all-cause death occurred in 107 (1.8%), 117 (1.9%), and 154 (2.6%) patients during the 2-year follow-up period. C-statistics of CrCl for each event were 0.609 (95% confidence interval, 0.559-0.658), 0.599 (0.548-0.657), and 0.746 (0.706-0.786); and those of eGFR were 0.542 (0.487-0.597), 0.573 (0.519-0.626), and 0.677 (0.631-0.723), respectively. C-statistics of CrCl for thromboembolism and all-cause death were significantly higher than those of eGFR (P < 0.001 for both). These results were consistent when BSA-unadjusted eGFR was used instead of eGFR (P = 0.002 for thromboembolism and P < 0.001 for all-cause death). CONCLUSIONS CrCl was superior to eGFR in the prediction of adverse outcomes, i.e., thromboembolism and all-cause death in Japanese patients with NVAF.
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Affiliation(s)
- Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
| | | | | | - Hirofumi Tomita
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Ken Okumura
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | - on behalf of the J-RHYTHM Registry Investigators
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
- Saiseikai Toyama Hospital, Toyama, Japan
- Minamihachioji Hospital, Tokyo, Japan
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Aomori, Japan
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
- The Cardiovascular Institute, Tokyo, Japan
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
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Kodani E, Atarashi H, Inoue H, Okumura K, Yamashita T, Origasa H. Impact of creatinine clearance on outcomes in patients with non-valvular atrial fibrillation: a subanalysis of the J-RHYTHM Registry. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 4:59-68. [PMID: 28950373 PMCID: PMC5862022 DOI: 10.1093/ehjqcco/qcx032] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/31/2017] [Indexed: 11/19/2022]
Abstract
Aims To clarify the influence of renal function on adverse outcomes in patients with non-valvular atrial fibrillation (NVAF), a post hoc analysis of the J-RHYTHM Registry was performed. Methods and results A consecutive series of outpatients with atrial fibrillation (AF) were enrolled from 158 institutions and followed for 2 years or until the occurrence of an event. Among 7406 patients with non-valvular AF, 6052 patients (69.8 ± 10.0 years, 71.2% men) with creatinine clearance (CrCl) value at baseline were divided into four groups according to CrCl level (<30, 30–49.9, 50–79.9, and ≥80 mL/min). Patients with CrCl <80 mL/min showed increased incidence of thromboembolism, major haemorrhage, all-cause and cardiovascular death, and composite events as compared with patients with CrCl ≥80 mL/min. After adjustment for multiple confounders, lower CrCl values emerged as independent predictors for thromboembolism [CrCl 30–49.9, hazard ratio (HR) 2.27, 95% confidence interval (CI) 1.09–4.72, P = 0.029; and CrCl 50–79.9, HR 1.99, 95% CI 1.07–3.72, P = 0.030] and all-cause death (CrCl <30, HR 6.44, 95% CI 3.03–13.7, P < 0.001; and CrCl 30–49.9, HR 3.14, 95% CI 1.54–6.41, P = 0.002), with CrCl ≥80 mL/min serving as a reference, whereas not for major haemorrhage. Warfarin treatment was associated with lower rates of composite events in patients with lower CrCl values of <80 mL/min. Conclusion Renal impairment was an independent predictor of adverse clinical outcomes except for major haemorrhage in Japanese patients with non-valvular AF. Warfarin was associated with lower rates of composite events in patients with lower CrCl values. Clinical Trial Registration: http://www.umin.ac.jp/ctr/. Unique identifier: UMIN000001569.
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Affiliation(s)
- Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School, Tama-Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo 206-8512, Japan
| | - Hirotsugu Atarashi
- Department of Internal Medicine and Cardiology, Nippon Medical School, Tama-Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo 206-8512, Japan
| | - Hiroshi Inoue
- Saiseikai Toyama Hospital, 33-1 Kusunoki, Toyama-shi, Toyama 931-8533, Japan
| | - Ken Okumura
- Saiseikai Kumamoto Hospital, 5-3-1 Chikami, Minami-ku, Kumamoto-shi, Kumamoto 861-4193, Japan
| | - Takeshi Yamashita
- The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-Ku, Tokyo 106-0031, Japan
| | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, 2630 Sugitani, Toyama-shi, Toyama 930-0194, Japan
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