Management of Adults with Newly Diagnosed Atrial Fibrillation With and Without Chronic Kidney Disease

2021 ◽  
pp. ASN.2021060744
Author(s):  
Nisha Bansal ◽  
Leila Zelnick ◽  
Kristi Reynolds ◽  
Teresa Harrison ◽  
Ming-Sum Lee ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Rate Control ◽  
Additional Data ◽  
Management Strategies ◽  
Healthcare Delivery ◽  
Newly Diagnosed ◽  
Limited Data ◽  
Health Records

Background: Atrial fibrillation (AF) is highly prevalent in chronic kidney disease (CKD) and is associated with worse cardiovascular and kidney outcomes. Limited data exist on use of AF pharmacotherapies and AF-related procedures by CKD status. We examined a large "real-world" contemporary population of incident AF to study the association of CKD with management of AF. Methods: We identified patients with newly diagnosed AF between 2010-2017 from two large, integrated healthcare delivery systems. Estimated glomerular filtration rate (eGFR) (≥60, 45-59, 30-44, 15-29, <15 ml/min/1.73 m2) was calculated from a minimum of two ambulatory serum creatinine measures separated by ≥90 days. AF medications and procedures were identified from electronic health records. We performed multivariable Fine-Gray subdistribution hazards regression to test the association of CKD severity with receipt of targeted AF therapies. Results: Among 115,564 incident AF patients, 34% had baseline CKD. In multivariable models, compared to those with eGFR>60 ml/min/1.73 m2, patients with eGFR 30-44 (adjusted hazard ratio [aHR] 0.91, 95%CI:0.99-0.93), 15-29 (aHR 0.78, 95%CI:0.75-0.82) and <15 ml/min/1.73 m2 (HR 0.64, 95%CI:0.58-0.70) had lower use of any AF therapy. Patients with eGFR 15-29 ml/min/1.73 m2 had lower adjusted use of rate control agents (aHR 0.61, 95%CI:0.56-0.67), warfarin (aHR 0.89, 95%CI:0.84-0.94) and DOACs (aHR 0.23, 95% CI:0.19-0.27) compared to patients with eGFR>60 ml/min/1.73 m2. These associations were even stronger for eGFR <15 ml/min/1.73 m2. There was also a graded association between CKD severity and receipt of AF-related procedures (vs. eGFR>60 ml/min/1.73 m2): eGFR 30-44 ml/min/1.73 (aHR 0.78, 95%CI:0.70-0.87), eGFR 15-29 ml/min/1.73 m2 (aHR 0.73, 95%CI:0.61-0.88) and eGFR<15 ml/min/1.73 m2 (aHR 0.48, 95%CI:0.31-0.74). Conclusions: In adults with newly diagnosed AF, CKD severity was associated with lower receipt of rate control agents, anticoagulation and AF procedures. Additional data on efficacy and safety of AF therapies in CKD populations are needed to inform management strategies.

scholarly journals Impact of antithrombotic therapy in the prognosis of atrial fibrillation patients with advanced chronic kidney disease

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
J.M Andreu Cayuelas ◽  
S Raposeiras-Roubin ◽  
E Fortuny Frau ◽  
A Garcia Del Egido ◽  
J Seller-Moya ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Antithrombotic Therapy ◽  
Anticoagulation Therapy ◽  
Bleeding Event ◽  
Funding Source ◽  
Newly Diagnosed ◽  
Bleeding Events ◽  
Cox Regression Analysis

Abstract Introduction Chronic kidney disease (CKD) is associated with an elevated thromboembolic and bleeding risk in atrial fibrillation (AF) patients, so the decision of antithrombotic therapy is a challenge. Purpose To analyze mortality, embolic and bleeding events in patients with advanced CKD and AF. Methods Multicentric retrospective registry on patients with AF and advanced CKD (CKD-EPI &lt;30 mL/min/1.73 m2). For death, multivariable Cox regression analysis was developed. For embolic and bleeding events, competing-risks regression based on Fine and Gray's proportional subhazards model was performed, being death the competing event Results We analysed 405 patients with advanced CKD and newly diagnosed AF. 57 patients were not treated with antithrombotic therapy (14.1%), 80 only with antiplatelet/s (19.8%), 211 only with anticoagulation (52.1%), and 57 with anticoagulant plus antiplatelet/s (14.1%). During a follow-up of 4.6±2.5 years, 205 died (50.6%), 34 had embolic events (8.4%) and 85 had bleeding outcomes (21.0%). Bleeding event rate was significantly lower in patients without antithrombotic therapy (Figure). After multivariate analysis, anticoagulant treatment was associated with higher bleeding rates, without differences in mortality or embolic events (Table). Conclusion Anticoagulation therapy was associated with a significant increase in bleeding events in patients with advanced CKD and newly diagnosed AF. None of the antithrombotic therapy regimens resulted in lower embolic events rate neither benefit in mortality. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): This study was supported by an unconditional grant from BMS-Pfizer

scholarly journals Chronic kidney disease and undiagnosed atrial fibrillation in individuals with diabetes

2020 ◽  
Vol 19 (1) ◽  
Author(s):  
Nam Ju Heo ◽  
Sang Youl Rhee ◽  
Jill Waalen ◽  
Steven Steinhubl
Keyword(s):  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Clinical Symptoms ◽  
Screening Program ◽  
Renal Involvement ◽  
Newly Diagnosed ◽  
Mortality And Morbidity ◽  
Increased Risk

Abstract Background Diabetes is an independent risk factor for atrial fibrillation (AF), which is associated with increases in mortality and morbidity, as well as a diminished quality of life. Renal involvement in diabetes is common, and since chronic kidney disease (CKD) shares several of the same putative mechanisms as AF, it may contribute to its increased risk in individuals with diabetes. The objective of this study is to identify the relationship between CKD and the rates of newly-diagnosed AF in individuals with diabetes taking part in a screening program using a self-applied wearable electrocardiogram (ECG) patch. Materials and methods The study included 608 individuals with a diagnosis of diabetes among 1738 total actively monitored participants in the prospective mHealth Screening to Prevent Strokes (mSToPS) trial. Participants, without a prior diagnosis of AF, wore an ECG patch for 2 weeks, twice, over a 4-months period and followed clinically through claims data for 1 year. Definitions of CKD included ICD-9 or ICD-10 chronic renal failure diagnostic codes, and the Health Profile Database algorithm. Individuals requiring dialysis were excluded from trial enrollment. Results Ninety-six (15.8%) of study participants with diabetes also had a diagnosis of CKD. Over 12 months of follow-up, 19 new cases of AF were detected among the 608 participants. AF was newly diagnosed in 7.3% of participants with CKD and 2.3% in those without (P < 0.05) over 12 months of follow-up. In a univariate Cox proportional hazard regression analysis, the risk of incident AF was 3 times higher in individuals with CKD relative to those without CKD: hazard ratios (HR) 3.106 (95% CI 1.2–7.9). After adjusting for the effect of age, sex, and hypertension, the risk of incident AF was still significantly higher in those with CKD: HR 2.886 (95% CI 1.1–7.5). Conclusion Among individuals with diabetes, CKD significantly increases the risk of incident AF. Identification of AF prior to clinical symptoms through active ECG screening could help to improve the clinical outcomes in individuals with CKD and diabetes.

scholarly journals Management and 1‐Year Outcomes of Patients With Newly Diagnosed Atrial Fibrillation and Chronic Kidney Disease: Results From the Prospective GARFIELD‐AF Registry

2019 ◽  
Vol 8 (3) ◽  
Author(s):  
Shinya Goto ◽  
Pantep Angchaisuksiri ◽  
Jean‐Pierre Bassand ◽  
A. John Camm ◽  
Helena Dominguez ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Newly Diagnosed ◽  
Link Type

See Editorial by Ding et al .

scholarly journals Apixaban vs. Warfarin in Atrial Fibrillation Patients With Chronic Kidney Disease

2021 ◽  
Vol 8 ◽  
Author(s):  
Chung-Ming Fu ◽  
Lung-Chih Li ◽  
Yueh-Ting Lee ◽  
Shih-Wei Wang ◽  
Chien-Ning Hsu
Keyword(s):  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Kidney Function ◽  
Major Bleeding ◽  
Lower Risk ◽  
Standard Dose ◽  
Healthcare Delivery ◽  
Real World Evidence ◽  
Record Data

Background and Objectives: Real-world evidence of apixaban treatment in patients with chronic kidney disease remains scarce. This study aimed to compare the relative risk of stroke or systemic embolism (SE) and major bleeding between apixaban and warfarin in atrial fibrillation (AF) patients with different degrees of kidney function.Design, Setting, Participants, and Measurements: We evaluated newly diagnosed AF patients between 2004 and 2018, who were receiving apixaban or warfarin. Electronic medical record data were collected from a large healthcare delivery network in Taiwan. The outcomes of hospitalization for stroke/SE and major bleeding were compared with propensity-score matched apixaban and warfarin cohorts. Stratified analyses according to initial apixaban dose (standard dose of 10 mg/day vs. lower dose of 2.5–5.0 mg/day) and baseline estimated glomerular filtration rate were performed.Results: Each cohort involved 1,625 matched patients. Apixaban was significantly associated with a lower risk of stroke/SE (adjusted hazard ratio [aHR]: 0.74; 95% confidence interval [CI]:0.57–0.97; p = 0.03). The risk of major bleeding was not increased whether in standard doses (aHR: 0.66; 95% CI: 0.45–0.96; p = 0.03) or reduced doses (aHR, 0.84; 95% CI, 0.63–1.12; p = 0.23) of apixaban. Regarding kidney function, apixaban reduced the risk of stroke/SE by 37% in those with an eGFR of &lt;30 ml/min/1.73 m2 (aHR: 0.63; 95% CI: 0.40–0.98; p = 0.04).Conclusions: Compared to warfarin, apixaban is associated with a reduced risk of stroke/SE and is consistent with a subset of AF patients with eGFR &lt;30 ml/min/1.73 m2. Both standard and reduced doses of apixaban showed lower risk of major bleeding than those of warfarin.

The predictor role of worsening renal function in patients with new onset atrial fibrillation on direct oral anticoagulant

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
L Bartoli ◽  
F Angeli ◽  
A Stefanizzi ◽  
P Paolisso ◽  
L Bergamaschi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Renal Function ◽  
Kidney Disease ◽  
Cardiovascular Events ◽  
Independent Predictor ◽  
Newly Diagnosed ◽  
Prognostic Role ◽  
Worsening Renal Function

Abstract Background Chronic kidney disease (CKD) is an important outcome predictor in patients with atrial fibrillation (AF). Moreover, renal function at baseline is used to guide oral anticoagulant (OA) selection and dosing at initial treatment. The prognostic role of worsening renal function (WRF) during treatment with direct oral anticoagulants (DOACS) has been poorly explored. Purpose To estimate the prognostic role of WRF in terms of major adverse cardiovascular events (MACEs) in a series of patients with newly diagnosed non-valvular AF (NVAF) treated with DOACs. Methods Among all patients with newly diagnosed NVAF and indication for OA between January 2017 and December 2018, we enrolled those treated with DOACs. Renal function at baseline and during follow-up was assessed with estimated glomerular filtration rates (eGFR). eGFR was calculated as a mean value of Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas. The hemorrhagic risk at baseline was estimated with the main available scores (HAS-BLED, ATRIA and ORBIT). WRF was defined as a decrease in eGFR of at least 20%. MACEs were evaluated according to the type of DOAC and the WRF. Major bleedings (MB) were defined according to the ISTH definition. Results The study population was constituted by 249 patients with newly diagnosed NVAF started on DOAC and followed for a median time of 14.1±8.6 months. Overall, WRF was observed in 58 cases (23.3%). Patients with WRF had significative higher rates of death (10.3% versus 3.1%, p=0.025) and MB (13.8% versus 4.7%, p=0.016). The incidence of bleeding events, acute coronary syndromes and stroke was not affected by WRF. Interestingly, CG formula better predicted the incidence of MB as compared to the other formulas (p=0.006). The type of DOAC did not significantly impact the observed renal impairment and had no effect on the occurrence of MACEs in patients showing WRF. The predictors of WRF were found to be age, female sex, low hemoglobin level and left ventricle end telediastolic volume. At multivariate analysis, WRF was identified as an independent predictor of MB (OR 3.1, 95% C.I, 1.12–8.58), regardless of the baseline bleeding risk. Conclusion This is the first prospective study to evaluate the impact of worsening renal function on cardiovascular events in patients with atrial fibrillation treated with DOACs. A significant WRF emerged as an independent predictor of death and MB. The specific DOAC did not affect either the entity of worsening renal function or the incidence of cardiovascular events. Funding Acknowledgement Type of funding source: None

scholarly journals Prevalence of Advanced Chronic Kidney Disease in Patients with Nonvalvular Atrial Fibrillation Hospitalized in Cardiology Departments

Kardiologiia ◽  
2020 ◽  
Vol 60 (2) ◽  
pp. 41-46 ◽  
Author(s):  
M. I. Chashkina ◽  
N. L. Kozlovskaya ◽  
D. A. Andreev ◽  
N. A. Ananicheva ◽  
A. A. Bykova ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Filtration Rate ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Newly Diagnosed ◽  
Nonvalvular Atrial Fibrillation ◽  
Advanced Chronic Kidney Disease ◽  
Sustained Reduction

Objective. To estimate the prevalence of chronic kidney disease (CKD) 3b – 5 stages and the newly diagnosed sustained reduction in glomerular filtration rate (GFR) <30 ml / min / 1.73 m2 in patients with atrial fibrillation (AF) in real clinical practice, as well as the features of their anticoagulant therapy.Materials and Methods. Retrospectively, data of all discharge epicrisis from cardiological departments of five Moscow hospitals from June 1, 2016 to May 31, 2017 were analyzed. Patients over 18 years old with AF were enrolled. At the next stage, patients with CKD 3 b – 5 st and newly diagnosed sustained reduction in GFR <30 ml / min / 1.73 m2 (at least 2 measurements during hospitalization) were selected.Results. Data of 9725 patients were analyzed, AF was diagnosed in 2983 (31 %) cases, of which a decreased GFR <45 ml / min / 1.73 m2 was detected in 27 % (n = 794) cases. Among them, 349 (44 %) were diagnosed with CKD 3b st, 123 (15 %) with CKD 4 st, 44 (6 %) with CKD 5 st, 278 (35 %) had a newly diagnosed sustained reduction in GFR. In 63 % of patients with AF and GFR <45 ml / min / 1.73 m2, anemia was diagnosed, 39 % of them had moderate and severe one. 711 (89 %) patients were prescribed anticoagulants, 53 % were assigned direct oral anticoagulants (DOACs). Patients with CKD 3 b st. more often rivaroxaban 15 mg (29 %) was prescribed, with CKD 4 and CKD 5 – warfarin (48 % and 25 %, respectively), in patients with newly diagnosed sustained reduction in GFR <30 ml / min / 1.73 m2 – apixaban 10 mg / day (16.2 %).Conclusion. A quarter of patients with AF revealed a decreased GFR <45 ml / min / 1.73 m2, half of them were recommended DOACs. 42 % of patients with GFR <30 ml / min / 1.72 m2 were prescribed DOACs, 27 % – warfarin. Patients with CKD 5 st DOACs were not assigned; in half of cases, none of the anticoagulants was recommended. Most often, the dose of the prescribed anticoagulant was not counted according to GFR in patients with newly diagnosed sustained reduction in GFR <30 ml / min / 1.73 m2.

scholarly journals 284 Worsening renal function as an outcome predictor in patients with new onset atrial fibrillation on direct oral anticoagulant

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Lorenzo Bartoli ◽  
Francesco Angeli ◽  
Matteo Armillotta ◽  
Angelo Sansonetti ◽  
Michele Fabrizio ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Renal Function ◽  
Kidney Disease ◽  
Oral Anticoagulant ◽  
Independent Predictor ◽  
Newly Diagnosed ◽  
Outcome Predictor ◽  
Prognostic Role ◽  
Worsening Renal Function

Abstract Aims In patients with atrial fibrillation (AF), baseline kidney function is used to guide oral anticoagulant (OA) selection and dosing, and chronic kidney disease (CKD) is a significant outcome predictor. However, the incidence of worsening renal function (WRF) and its prognostic role during treatment with direct oral anticoagulants (DOACS) has been poorly explored. To assess the prognostic role of WRF in terms of bleedings and major adverse cardiovascular events (MACEs) in a cohort of patients with newly diagnosed non-valvular AF (NVAF) treated with DOACs. Methods and results Between January 2017 and March 2019, we enrolled all the patients with newly diagnosed NVAF and OA indication, treated with DOACs. Renal function was assessed using the mean value of the estimated glomerular filtration rates (eGFR) calculated using Cockcroft–Gault (CG), modification of diet in renal disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas. CHA2DS2-VASc and HAS-BLED scores were used at baseline to estimate the ischaemic and haemorrhagic risk, respectively. At follow-up, WRF was identified as a decrease in eGFR of at least 20% while bleedings were classified according to the international society of thrombosis and haemostasis (ISTH) criteria. Finally, we defined AF progression as the transition from paroxysmal to persistent or permanent AF or from persistent to permanent AF. 1009 patients with newly diagnosed NVAF started on DOAC were enrolled. They were followed-up for 21.6 ± 9.5 months. Overall, WRF was observed in 181 cases (18%). Patients with WRF had higher rates of progression of AF (18.5% vs. 11.8%, P = 0.02), MACEs (20.4% vs. 12.9%, P = 0.09) and major bleedings (MBs) (9.4% vs. 4.7%, P = 0.013). WRF did not correlate with all bleedings, stroke, or acute coronary syndrome (ACS). However, those who presented WRF using CKD-EPI formula had higher ACS incidence (6.1% vs. 2.5%, P = 0.015), and generally better-predicted MACEs. At multivariate analysis adjusted for age, hypertension, baseline HAS-BLED score and WRF, the latter emerged as an independent predictor of MB (OR: 1.9, 95% CI: 1.059–3.51). Conclusions In patients with newly diagnosed NVAF treated with DOACs, WRF is associated with AF progression and MACEs, and emerged as an independent predictor of major bleedings. WRF evaluated with CKD-EPI formula better predicted MACEs.

The Problem of Atrial Fibrillation in Patients with Chronic Kidney Disease

2016 ◽  
Vol 14 (3) ◽  
pp. 260-265 ◽  
Author(s):  
Beata Franczyk ◽  
Anna Gluba-Brzózka ◽  
Aleksandra Cia|kowska-Rysz ◽  
Maciej Banach ◽  
Jacek Rysz
Keyword(s):  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Kidney Disease

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 &lt;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&lt;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

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