Inadequate anticoagulation by Vitamin K Antagonists is associated with Major Adverse Cardiovascular Events in patients with atrial fibrillation

Background One-third of atrial fibrillation (AF) patients have chronic kidney disease (CKD), a condition that itself increases thromboembolic and major bleeding risks, especially in patients with severe CKD. Bleeding would be accentuated by suboptimal anticoagulation control with vitamin K antagonists (VKA). Purpose This article aimed to investigate the incidence of cardiovascular events, mortality and quality of anticoagulation in relation to CKD in a ‘real-world’ prospective cohort of AF patients included in the FANTASIIA registry. Methods We analysed consecutive AF patients who were prospectively recruited with a year of follow-up. The quality of anticoagulation was estimated by time in therapeutic range (TTR). The annual incidence of events was analysed. Results We studied 1,936 patients (male: 55.7%, mean: 73.8 ± 9.4 years): 445 (22.9%) had normal function, 698 (36.1%) had mild CKD, 713 (36.8%) had moderate CKD and 80 (4.2%) had severe CKD. Patients with estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2 (severe CKD) had lower TTR (53.3 ± 25.6% vs. 61.8 ± 25.1%, p = 0.007) and higher proportion of poor TTR (67.2 vs. 51.8%; p = 0.014) than patients with eGFR ≥30 mL/min/1.73 m2. Severe CKD was significantly associated with cardiovascular mortality (hazard ratio [HR]: 9.33; p = 0.002), major bleeding (HR: 2.94; p = 0.036) and major adverse cardiovascular events (MACE) (HR: 4.93; p = 0.004). Importantly, 375 patients (21.1%) showed a deteriorating eGFR of ≥10 mL/min during the follow-up, with significantly higher mortality and cardiovascular events. Conclusion In a prospective and real-world AF registry, approximately 67% of patients with severe CKD had poor anticoagulation control while taking VKA. The presence of severe CKD was an independent factor for cardiovascular mortality, MACE and major bleeding. Worsening eGFR of only ≥10 mL/min during follow-up was significantly associated with mortality and major bleeding.

Download Full-text

TIMI-AF score and cardiovascular events in vitamin K antagonists-naïve outpatients with atrial fibrillation

Clinical Cardiology ◽

10.1002/clc.23035 ◽

2018 ◽

Vol 41 (9) ◽

pp. 1252-1258 ◽

Cited By ~ 1

Author(s):

Alejandro Isidoro Pérez Cabeza ◽

Rafael Bravo Marques ◽

Pedro Antonio Chinchurreta Capote ◽

Francisco Ruiz Mateas ◽

Christina L. Fanola ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Cardiovascular Events ◽

Vitamin K Antagonists

Download Full-text

Reply to: “Inadequate anticoagulation by vitamin K antagonists and major adverse cardiovascular events other than stroke”

International Journal of Cardiology ◽

10.1016/j.ijcard.2015.10.122 ◽

2016 ◽

Vol 202 ◽

pp. 934-935

Author(s):

Daniele Pastori ◽

Pasquale Pignatelli ◽

Mirella Saliola ◽

Roberto Carnevale ◽

Tommasa Vicario ◽

...

Keyword(s):

Vitamin K ◽

Cardiovascular Events ◽

Vitamin K Antagonists ◽

Major Adverse Cardiovascular Events

Download Full-text

Inadequate anticoagulation by Vitamin K antagonists and major adverse cardiovascular events other than stroke

International Journal of Cardiology ◽

10.1016/j.ijcard.2015.09.112 ◽

2016 ◽

Vol 202 ◽

pp. 933

Author(s):

Mehmet Eyuboglu

Keyword(s):

Vitamin K ◽

Cardiovascular Events ◽

Vitamin K Antagonists ◽

Major Adverse Cardiovascular Events

Download Full-text

New Drugs for Thromboembolic Prevention in Atrial Fibrillation

European Cardiology Review ◽

10.15420/ecr.2010.6.4.64 ◽

2010 ◽

Vol 6 (4) ◽

pp. 64

Author(s):

Jose L Merino ◽

Jose López-Sendón ◽

◽

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Negative Impact ◽

Vitamin K Antagonists ◽

Coagulation Factor ◽

Developed Countries ◽

New Drugs ◽

Risk Scores ◽

Bleeding Events ◽

Risk Patients

Atrial fibrillation (AF) is the most frequent sustained arrhythmia and its prevalence is increasing in developed countries. This progressive increase and the negative impact of this arrhythmia on the patient’s prognosis make AF one of the main healthcare problems faced today. This has led to intense research into the main aspects of AF, one of them being thromboembolism prevention. AF patients have a four to five times higher risk of stroke than the general population. Several factors increase thromboembolic risk in patients with AF and the use of risk scores, such as the Congestive Heart Failure, Hypertension, Age Greater than 75, Diabetes, and Prior Stroke or Transient Ischemic Attack (CHADS2), have been used to identify the best candidates for anticoagulation. Antithrombotic drugs are the mainstay of therapy for embolic prevention. The clinical use of these drugs is based on the risk–benefit ratio, where benefit is the reduction of stroke and systemic embolic events and risk is mostly driven by the increase in bleeding events. Generally, antiplatelets are indicated for low-risk patients in light of the fact anticoagulants are the drug of choice for moderate- or high-risk patients. Vitamin K antagonists have been the only option for oral anticoagulation for the last 50 years. However, these drugs have many pharmacodynamic and pharmacokinetic problems. The problems of anticoagulation with vitamin K antagonists have led to the investigation of new drugs that can be administered orally and have a better dose–response relationship, a shorter half-life and, in particular, higher efficacy and safety without the need for frequent anticoagulation controls. The drugs that have been studied most thoroughly in patients with AF are inhibitors of the activated coagulation factor X and inhibitors of coagulation factor II (thrombin), including ximelagatran and dabigatran. In addition, non-pharmacological therapies have been developed to prevent recurrent embolism in certain patient populations.

Download Full-text

Perception of Patients Regarding Burdens and Benefits of Vitamin K Antagonists Among Patients with Nonvalvular Atrial Fibrillation

Cardiovascular & Hematological Agents in Medicinal Chemistry ◽

10.2174/1871525716666180608075834 ◽

2019 ◽

Vol 16 (2) ◽

pp. 106-113 ◽

Cited By ~ 1

Author(s):

Carlos Escobar ◽

Vivencio Barrios ◽

Luis Prieto ◽

Jose María Lobos ◽

Jose Polo ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Vitamin K Antagonists ◽

Nonvalvular Atrial Fibrillation

Download Full-text

Anticoagulation in Atrial Fibrillation Cardioversion: What Is Crucial to Take into Account

Journal of Clinical Medicine ◽

10.3390/jcm10153212 ◽

2021 ◽

Vol 10 (15) ◽

pp. 3212

Author(s):

Fabiana Lucà ◽

Simona Giubilato ◽

Stefania Angela Di Fusco ◽

Laura Piccioni ◽

Carmelo Massimiliano Rao ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Thrombus Formation ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Anticoagulation Therapy ◽

Significant Advance ◽

Thromboembolic Events ◽

Thromboembolic Risk ◽

Pharmacological Cardioversion

The therapeutic dilemma between rhythm and rate control in the management of atrial fibrillation (AF) is still unresolved and electrical or pharmacological cardioversion (CV) frequently represents a useful strategy. The most recent guidelines recommend anticoagulation according to individual thromboembolic risk. Vitamin K antagonists (VKAs) have been routinely used to prevent thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) represent a significant advance due to their more predictable therapeutic effect and more favorable hemorrhagic risk profile. In hemodynamically unstable patients, an emergency electrical cardioversion (ECV) must be performed. In this situation, intravenous heparin or low molecular weight heparin (LMWH) should be administered before CV. In patients with AF occurring within less than 48 h, synchronized direct ECV should be the elective procedure, as it restores sinus rhythm quicker and more successfully than pharmacological cardioversion (PCV) and is associated with shorter length of hospitalization. Patients with acute onset AF were traditionally considered at lower risk of thromboembolic events due to the shorter time for atrial thrombus formation. In patients with hemodynamic stability and AF for more than 48 h, an ECV should be planned after at least 3 weeks of anticoagulation therapy. Alternatively, transesophageal echocardiography (TEE) to rule out left atrial appendage thrombus (LAAT) should be performed, followed by ECV and anticoagulation for at least 4 weeks. Theoretically, the standardized use of TEE before CV allows a better stratification of thromboembolic risk, although data available to date are not univocal.

Download Full-text