scholarly journals Plasma natriuretic peptide level is an independent determinant of major clinical outcomes in atrial fibrillation patients without heart failure: the Fushimi AF Registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
Y Hamatani ◽  
M Iguchi ◽  
Y Aono ◽  
K Ishigami ◽  
S Ikeda ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Clinical Outcomes ◽  
Prognostic Marker ◽  
Oral Anticoagulants ◽  
Systemic Embolism ◽  
The Mean

Abstract Background Atrial fibrillation (AF) increases the risk of death, stroke/systemic embolism and heart failure (HF). Plasma natriuretic peptide (NP) level is an important prognostic marker in HF patients. However, little is known regarding the prognostic significance of plasma NP level in AF patients without HF. Purpose The aim of this study is to investigate the relationship between plasma NP level and clinical outcomes such as all-cause death, stroke/systemic embolism and HF hospitalization during follow-up period in AF patients without HF. Methods The Fushimi AF Registry is a community-based prospective survey of AF patients in our city. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,466 patients by the end of November 2019. From the registry, we excluded 1,220 patients without a pre-existing HF (defined as having one of the following; prior hospitalization for HF, New York Heart Association class ≥2, or left ventricular ejection fraction <40%). Among 3,246 AF patients without HF, we investigated 1,189 patients with the data of plasma BNP (n=401) or N-terminal pro-BNP (n=788) level at the enrollment. We divided the patients according to the quartile of each plasma BNP or NT-pro BNP level and compared the backgrounds and outcomes between these 4 groups stratified by plasma NP level. Results Of 1,189 patients, the mean age was 72.1±10.2 years, 454 (38%) were female and 684 (58%) were paroxysmal AF. The mean CHADS2 and CHA2DS2-VASc score were 1.6±1.1 and 2.9±1.5, respectively. Oral anticoagulants were prescribed in 671 (56%) at baseline. The median (interquartile range) BNP and N-terminal pro-BNP level were 84 (38, 176) and 500 (155, 984) pg/ml, respectively. Patients with high plasma NP level were older, and demonstrated lower prevalence of paroxysmal AF, higher CHADS2 and CHA2DS2-VASc scores and higher prevalence of chronic kidney disease and oral anticoagulants prescription (all P<0.01). A total of 165 all-cause death, 114 stroke/systemic embolism and 103 HF hospitalization occurred during the median follow-up period of 5.0 years. Kaplan-Meier curves demonstrated that higher plasma NP level was significantly associated with the incidences of all-cause death, stroke/systemic embolism and HF hospitalization in AF patients without HF (Figure 1A). Multivariable Cox regression analysis revealed that plasma NP level could stratify the risk of clinical outcomes even after adjustment by type of AF, CHA2DS2-VASc score, chronic kidney disease and oral anticoagulant prescription (Figure 1B). Conclusion Plasma NP level is a significant prognostic marker for all-cause death, stroke/systemic embolism and HF hospitalization in AF patients without HF, suggesting the importance of measuring plasma NP level in AF patients even without HF. Figure 1 Funding Acknowledgement Type of funding source: None

Beta-blockers in elderly patients with left ventricular systolic dysfunction and chronic kidney disease: danger or benefit?

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
J Martinez Milla ◽  
M Cortes ◽  
M Lopez-Castillo ◽  
A Devesa-Arbiol ◽  
A.L Rivero-Monteagudo ◽  
...  
Keyword(s):  
Heart Failure ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Propensity Score ◽  
Ejection Fraction ◽  
Beta Blockers ◽  
Hospital Records ◽  
Propensity Score Matching Analysis ◽  
The Mean

Abstract Introduction Beta-blockers (BB) have been shown to reduce mortality in patients with HFrEF. However, there is little data on the benefit of these therapies in patients with chronic kidney disease and even less in older patients. The aim of this work is to evaluate the role of beta-blockers in patients ≥75 years along the spectrum of kidney disease. Methods From January 2008 to July 2014, we consecutively enlisted 802 patients aged >75 years that had ejection fraction ≤35%. From this group we included 380 patients that had CKD (defined as a glomerular filtration rate (GFR) ≤60 ml/min/1.73m2). Clinical, echocardiographic and electrocardiographic data were taken from hospital records. Follow-up was made via telephone and hospital records as well. Propensity score matching analysis was made to assess the relationship between treatment with BB and occurrence of major adverse cardiovascular event (MACE) composite of death for any cause or heart failure. hospitalization. Multivariate Cox regression analysis was also made in the different groups of CKD (45–60 ml/min/1.73m2, 30–45 ml/min/1.73m2, <30 ml/min/1.73m2) in order to assess the effect of BB over mortality and CV events in each subgroup. Results 390 patients were included. Male represented 62.3% of all participants, and the mean age was 82.6±4.1 years. The mean ejection fraction was 27.9±6.5%. Ischemic etiology was found in 50.6% of cases. Glomerular filtrate (GF) was 60 to 45 ml/min/1.73 m2 in 50.3% of patients, 45–30 ml/min/1.73 m2 in 37.4% and <30 ml/min/1.73 m2 in 12.3%. At the end of the follow-up, 67.4% of the patients were on beta-blocker treatment. The mean follow-up was 32±23 months. During the study period, 211 patients (54.1%) died and 257 patients (65.9%) had a major cardiovascular event (death or hospitalization for heart failure). After propensity score matching analysis, 178 were considered (89 each group) and they have no significant difference in baseline characteristics. BBs were found to significantly reduce mortality (HR 0.45 (95% CI, 0.27–0.75). When the effect of BB over the different subgroups of CKD was analyzed, it was seen also that BB reduced mortality in patients with eGFR 45–60 ml/min/1.73 m2 (HR 0.47 (95% CI, 0.26–0.86), in patients with eGFR 30–45 ml/min/1.73 m2 (HR 0.55 (95% CI, 0.26–1.06)and in eGFR <30 ml/min/1.73 m2 (HR 0.29 (95% CI, 0.11–0.76) Conclusion The use of beta-blockers in elderly patients with HFrEF and kidney DISEASE was associated with increased survival, regardless of the degree of kidney failure. There is a need to raise awareness of the benefits of beta-blocker use in these patients to promote their use where possible. Funding Acknowledgement Type of funding source: None

P0670DIFFUSIONAL KURTOSIS IMAGING PREDICTS THE PROGNOSIS OF CHRONIC KIDNEY DISEASE

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Yan Liu ◽  
Gu-mu-yang Zhang ◽  
Xiaoyan Peng ◽  
Xuemei Li ◽  
Hao Sun ◽  
...  
Keyword(s):  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Iga Nephropathy ◽  
Clinical Outcomes ◽  
Renal Fibrosis ◽  
Prognostic Value ◽  
Mean Value ◽  
Non Invasive ◽  
The Mean

Abstract Background and Aims Renal fibrosis is the strongest prognosis predictor of ESRD in chronic kidney disease (CKD), but non-invasive and repeatable imaging markers are missing. Magnetic resonance imaging (MRI) has wide range of applications in renal parenchymal diseases, and diffusional kurtosis imaging (DKI) is a new promising noninvasive method of MRI which can provide more information about non-Gaussian diffusion using a polynomial model. We had successfully used DKI to assess renal fibrosis in IgA nephropathy in our previous work. This study aimed to evaluate the prognostic value of DKI in CKD. Method We prospectively enrolled forty-two CKD patients in our study in Jan. 2017. On recruitment, the basic clinical data were documented, and DKI was performed on a clinical 3T MR scanner. Region-of-interest (ROI) measurements were performed to determine apparent diffusion coefficient (ADC), kurtosis (K) and diffusivity (D) of the cortex of the kidneys. We had followed up these patients for 3 years, and collected all the clinical data and outcomes. The prognostic value of DKI metrics and clinical parameters were investigated. Results Forty-two patients consisted of 26 males and 16 females with mean age of 41.3±15.4 years. The most common etiology was IgA nephropathy (25/42, 59.5%). At baseline, the mean value of serum creatinine (SCr) was 224.4±156.2μmol/L. Among them, 18 patients had eGFR≥45ml/min and 24 patients had eGFR<45ml/min. According to the etiology and CKD classification, all the patients had received appropriate treatment. Besides supportive treatment and management of CKD complications, 21 patients (50%) had received corticosteroid and/or immunosuppressants treatment. After 36 months follow up, 12 patients had progressed to end stage renal disease (ESRD), and the mean value of SCr of the remaining 30 patients was 153.0±78.8umol/L. The Kaplan-Meyer survival regression showed that the patients with eGFR<45ml/min had worse clinical outcomes (p=0.0006). ROC analysis and Kaplan-Meyer survival regression showed that DKI metrics (K≥0.66 or ADC<1.35) not only predicted severe renal fibrosis, but also had worse clinical outcomes (p=0.01 and p<0.0001) (Figure 1). According to the COX regression analysis, both K (K≥0.66, HR 4.676, 95%CI 1.262-17.325) and ADC (ADC<1.35, HR 13.118, 95%CI 3.499-49.178) values, but not age, gender and eGFR group (cut-off value: 45ml/min), were the independent risk factors for the progression to ESRD. Conclusion Renal ADC and K values obtained from DKI showed significant predictive value for the prognosis of CKD, could be a promising non-invasive technique in patients follow-up.

scholarly journals Bleeding Risk of Direct Oral Anticoagulants in Patients With Heart Failure And Atrial Fibrillation

2021 ◽  
Vol 14 (2) ◽  
Author(s):  
Cynthia A. Jackevicius ◽  
Lingyun Lu ◽  
Zunera Ghaznavi ◽  
Alberta L. Warner
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Renal Function ◽  
Kidney Disease ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Hazard Ratio ◽  
Patients With Heart Failure

Background: Patients with heart failure and atrial fibrillation are an important atrial fibrillation subgroup in which direct oral anticoagulants (DOACs) have not been adequately studied in real-world settings. Since DOACs rely on renal elimination and renal dysfunction is prevalent in patients with heart failure, their use may increase bleeding risk, negating some of their advantage over warfarin. Methods: We conducted a retrospective cohort study using linked Veterans Administration databases of patients with heart failure newly started on warfarin or DOACs for atrial fibrillation from October 2010 to August 2017 (23 635 warfarin, 25 823 DOAC). Outcomes included time to first bleeding, stroke, and death using Cox proportional hazards models with inverse probability of treatment weighting. Results: Total bleeding (hazard ratio, 0.62 [95% CI, 0.56–0.68]), major bleeding (hazard ratio, 0.49 [95% CI, 0.40–0.61]), and death (hazard ratio, 0.74 [95% CI, 0.71–0.78]) were lower with DOAC than warfarin, and with apixaban and dabigatran, but not rivaroxaban. Moderate/severe chronic kidney disease was common (48.7%); moderate chronic kidney disease was associated with increased bleeding with DOACs but not warfarin. However, death and bleeding remained lower with DOACs than warfarin across all renal function levels and clinical subgroups. A >20% transient/persistent decline in renal function occurred in 53% of DOAC-treated patients at some point during follow-up, would have required dose reduction in 10.5% of patients, and was associated with increased bleeding. Dose adjustments were made more often, and bleeding and death were lower in patients seen by pharmacists or anticoagulation clinics. There were significant between-site variations in DOAC dosing. Conclusions: DOACs overall, apixaban, and dabigatran, but not rivaroxaban, were associated with less total bleeding and death than warfarin in patients with heart failure and atrial fibrillation at all levels of renal function. Renal function decline resulted in increased bleeding in patients with DOACs. DOAC dose adjustment was often indicated, associated with increased bleeding when not adjusted, emphasizing the need for closer monitoring in these patients.

P6251Prognostic value of ACEi/ARBS in elderly patients with heart failure with reduced ejection fraction with and without chronic kidney disease

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J Martinez Milla ◽  
M Cortes ◽  
M Lopez-Castillo ◽  
A Devesa ◽  
A L Rivero-Monteagudo ◽  
...  
Keyword(s):  
Heart Failure ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Ejection Fraction ◽  
Elderly Patients ◽  
Left Ventricular Ejection ◽  
Hospital Records ◽  
Patients With Heart Failure ◽  
The Mean

Abstract Introduction Angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers therapy (ACEI/ARB) have shown to reduce mortality in patients with heart failure and reduced left ventricular ejection fraction (HFrEF). However, there is lack of information about the benefit of these drugs in patients with chronic kidney disease (CKD), and even less in elderly patients. Our aim is to compare the prognostic impact of ACE/ARB if CKD is present or not Methods From January 2008 to July 2014, we consecutively enlisted 802 patients aged >75 years that had ejection fraction ≤35%. Clinical, echocardiographic and ECG data were taken from hospital records. Follow-up was made via telephone and hospital records as well. We analyzed the relationship between treatment with ACEi/ARBs (with different doses) and occurrence of mortality or MACE (major adverse cardiovascular events: composite of death from any cause or hospitalization for heart failure). Results From the total population 410 (51%) patients that had not CKD (glomerular filtration rate (GFR) >60ml/min/1,73m2) and 390 (49%) patients had CKD (with GFR ≤60ml/min/1,73m2). We analyze the population according the presence or not of CKD. Both groups had similar characteristics except the age: 81.5±4.5 years vs. 82.6±4.1 (p<0.05) and the percentage of use of ACEi/ARB 78.8% of the total vs 66.9% of the total (p<0.05). The mean ejection fraction was 27.9±6.5% vs 28.12±6.5% (p>0.05). The mean follow up was 33±22 vs 32±23 months (p>0.05). In patients with no CKD 170 (42%) patients died and 239 (58%) patients had a MACE. In the CKD group 211 (54.1%)patients died and 257 (65.9%)patients had a major cardiovascular event. In the univariate analysis in both groups the use of ACEi/ARB reduced the mortality and the MACE. After a multivariate analysis ACEi/ARB appear to be beneficial in the CKD group (OR 0.71 [0.50–0.98]) but not in no CKD group Conclusions According to our data, treatment with ACEI/ARB in elderly patients HFrEF and CKD should be encouraged even more than in those without CKD.

scholarly journals Direct-Acting Oral Anticoagulants Versus Warfarin in Medicare Patients With Chronic Kidney Disease and Atrial Fibrillation

Stroke ◽  
2020 ◽  
Vol 51 (8) ◽  
pp. 2364-2373 ◽  
Author(s):  
James B. Wetmore ◽  
Nicholas S. Roetker ◽  
Heng Yan ◽  
Jorge L. Reyes ◽  
Charles A. Herzog
Keyword(s):  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Systemic Embolism ◽  
Intention To Treat ◽  
Hazard Ratios ◽  
Direct Acting ◽  
Direct Acting Oral Anticoagulants

Background and Purpose: The comparative effectiveness of direct-acting oral anticoagulants, compared with warfarin, for risks of stroke/systemic embolism, major bleeding, or death have not been studied in Medicare beneficiaries with atrial fibrillation and nondialysis-dependent chronic kidney disease. Methods: Medicare data from 2011 to 2017 were used to identify patients with stages 3, 4, or 5 chronic kidney disease and new atrial fibrillation who received a new prescription for warfarin, apixaban, rivaroxaban, or dabigatran. We estimated marginal hazard ratios with 95% CIs for the association of each direct-acting oral anticoagulant, compared with warfarin, for the outcomes of interest using inverse-probability-of-treatment weighted Cox proportional hazards models in as-treated and intention-to-treat analyses. Results: A total of 22 739 individuals met criteria (46.3% warfarin, 29.6% apixaban, 17.2% rivaroxaban, 6.9% dabigatran). Across the groups of anticoagulant users, mean age was 78.4 to 79.0 years; 50.3% to 51.4% were women, and 80.3% to 82.8% had stage 3 chronic kidney disease. In the as-treated analysis, for stroke/systemic embolism, hazard ratios, all compared with warfarin, were 0.70 (0.51–0.96) for apixaban, 0.80 (0.54–1.17) for rivaroxaban, and 1.15 (0.69–1.94) for dabigatran. For major bleeding, analogous hazard ratios were 0.47 (0.37–0.59) for apixaban, 1.05 (0.85–1.30) for rivaroxaban, and 0.95 (0.70–1.31) for dabigatran. There was no difference in the risk of all-cause mortality between the direct-acting oral anticoagulants and warfarin. Results of the intention-to-treat analysis were similar. Conclusions: Apixaban, compared with warfarin, was associated with decreased risk of stroke/systemic embolism and major bleeding; risks for both outcomes with rivaroxaban and dabigatran did not differ from risks with warfarin.

scholarly journals Impacts of off-label dosing noacs on clinical outcomes in very elderly patients with atrial fibrillation

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
T Chao ◽  
Y.H Chan ◽  
G.Y.H Lip ◽  
S.A Chen
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Outcomes ◽  
Major Bleeding ◽  
Lower Risk ◽  
Oral Anticoagulants ◽  
Systemic Embolism ◽  
Very Elderly ◽  
Off Label ◽  
Funding Sources ◽  
Clinical Events

Abstract Background Studies about the comparisons of on-label and off-label dosing non-vitamin K antagonist oral anticoagulants (NOACs) regarding the risks of clinical outcomes among atrial fibrillation (AF) patients have been published. However, data among the very elderly AF patients were limited. In the present study, we aimed to investigate the impacts of inappropriate dosing of NOACs on clinical outcomes in AF patients aged ≥85 years of age. Methods We used medical data from a multi-center healthcare system in Taiwan enrolling 1,836 and 268 AF patients aged ≥85 years treated with NOACs and warfarin, respectively. Among 1,836 patients receiving NOACs, underdosing, overdosing and on-label dosing NOACs were prescribed in 248, 149 and 1439 patients, respectively. The risks of ischemic stroke/systemic embolism (IS/SE) and major bleeding were compared between warfarin and NOACs in different dosing groups. Also, the risks of clinical events of underdosing and overdosing NOACs were comapred to on-labeling dosing. Results Compared to warfarin, underdosing NOACs were associated with a higher risk of IS/SE (aHR 2.39; p=0.048) without a lower risk of major bleeding; while overdosing NOACs were not associated with a lower risk of IS/SE (aHR 0.74, p=0.604) (Figure 1). Compared to on-label dosing NOACs, underdosing NOACs were associated with a higher risk of IS/SE, while the risk was not lower for overdoing NOACs (Figure 2). Conclusions Even for very elderly AF patients aged ≥85 years, NOACs should still be prescribed at the dosing following the criteria defined in clinical trials and guideline recommendations. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2

Abstract TP138: Chronic Kidney Disease in Heart Failure Patients is Associated with Increased Prevalence of Atrial Fibrillation or Atrial Flutter as well as CVA/TIA

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Christopher Lu ◽  
Jack Chan ◽  
Zejia Yu ◽  
Paula Anzenberg ◽  
Mikhail Torosoff
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Atrial Flutter ◽  
Stroke Risk ◽  
Multivariate Logistic Regression Analysis ◽  
History Of ◽  
Get With The Guidelines

Background: The CHADS-VASC score does not incorporate renal dysfunction in stroke risk assessment in patients with atrial fibrillation and the prevalence of atrial fibrillation, atrial flutter, and cerebrovascular accidents (CVA) in patients with concurrent CHF and CKD is not well investigated. Objective: Evaluate the prevalence of history of stroke, atrial fibrillation, atrial flutter in patients with CHF and CKD. Methods: Data from the single institution Get With The Guidelines- Heart Failure (GWG-HF) cohort of 2938 consecutive inpatients with known GFR was utilized. CHADS-VASC score was calculated from the GWG-HF variables. Chronic kidney disease (CKD) was defined as GFR <60 ml/min. Results: An overwhelming majority (95%) of GWG-HF patients had elevated >1 CHADS-VASC score, which was also significantly more common in patients with CKD (97.6% vs. 91.7% in patients without CKD, p<0.0001). Average CHADS-VASC score was also significantly increased in patients with CKD (4+/-1.3 vs. 3.3+/-1.4, p<0.0001). Furthermore, CKD was associated with increased prevalence of atrial fibrillation and/or flutter (45.6% vs. 35.3%, p<0.0001) and stroke history (17.5% vs. 12.3%, p=0.002). When stroke and TIA histories were removed from the CHADS-VASC score ("CHAD-VASC score"), the remaining variables were strongly predictive of stroke or TIA (14.2% vs. 3.8%, p<0.0001). In multivariate logistic regression analysis, both CHAD-VASC score (OR 2.6, 95%CI 1.3-5.4, p=0.009) and CKD (OR 1.5, 95%CI 1.2-1.8, p=0.001) were associated significantly increased odds of prior stroke or TIA. Conclusions: In patients admitted with heart failure, CKD is associated with increased prevalence of atrial fibrillation or atrial flutter as well as increased prevalence of CVA/TIA. Further prospective studies are warranted to examine whether CKD history should be included in stroke risk assessment in patients with atrial fibrillation or atrial flutter, in conjunction with existing risk assessment frameworks.

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