Stroke and Major Bleeding when Switching from Warfarin to Apixaban in Patients with Advanced Chronic Kidney Disease and Prevalent Atrial Fibrillation

Abstract Background Apixaban is the most widely used direct oral anticoagulant in patients with chronic kidney disease (CKD). Data on the incidence of stroke and major bleeding after switching from warfarin to apixaban in patients with prevalent atrial fibrillation (AF) and CKD are limited.Methods Warfarin users with stage 4-5 CKD not on dialysis and non-valvular AF prior to Jan 1,2012 were identified from the United States Data Renal System CKD dataset and individuals switching to apixaban from Jan 1,2012 -Dec 31, 2015 were identified. The incidence of stroke (ischemic or hemorrhagic), transient ischemic attack, or systemic thromboembolism and major bleeding events were estimated. Outcomes were compared between individuals switching to apixaban and those continuing warfarin using survival analyses with inverse probability treatment weighting. Individuals were censored at the time of anticoagulation discontinuation, loss of Medicare part D coverage, dialysis, kidney transplant, a 2nd switch in anticoagulant class, or death. Results 1762 individuals with advanced CKD and AF were initially on warfarin; 71 (4.0%) switched to apixaban (57.8% male, mean age 78.2 years (SD ±6.6), 78.9% white, mean CHA2DS2-VASc 5.0 (SD ±1.5), mean HAS-BLED 2.2 (SD ±0.5) and 1691 (96.0%) continued warfarin (47.6% male, mean age 80.1 years (SD ±8.7), 87.9% white, mean CHA2DS2-VASc 5.5 (SD ±1.6), mean HAS-BLED 2.5 (SD ±0.8). The incidence of stroke in the apixaban switch and warfarin continuation groups were 0.02/patient-year (95%CI 0.002-0.12) and 0.06/patient-year (95%CI 0.05-0.07) (p=0.21). Incidence of major bleeding were 0.02/patient-year (95% CI 0.002-0.13) and 0.06 (95% CI 0.03-0.04) (p =0.44) in the switch and warfarin groups, respectively. In adjusted models, the risk of stroke (HR 0.27 (95% CI 0.04-1.99)) and major bleeding (HR 0.41 (95% CI 0.06-3.02)) trended lower in the apixaban switch compared to the warfarin continuation group.Conclusions The incidence and risk of stroke and major bleeding trended lower in individuals with stage 4-5 CKD and prevalent AF who switched from warfarin to apixaban than individuals continuing warfarin. Our findings support a strategy of switching prevalent AF patients with late stage CKD from warfarin to apixaban. Additional studies including a larger number of events with a longer-duration of follow-up are needed to refine effect estimates.

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Abstract P682: Risk of All Cause Stroke and Major Bleeding Events When Switching From Warfarin to Apixaban in Patients With Advanced Chronic Kidney Disease and Prevalent Atrial Fibrillation

Stroke ◽

10.1161/str.52.suppl_1.p682 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Katherine Garlo ◽

Thomas Mavrakanas ◽

Elisabeth Burdick ◽

Wei Wang ◽

David Charytan

Keyword(s):

Atrial Fibrillation ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Major Bleeding ◽

The United States ◽

Bleeding Events ◽

Part D ◽

Major Bleeding Events ◽

Ischemic Attack ◽

Direct Acting

Introduction: Apixaban is the preferred direct acting oral anticoagulant in patients with chronic kidney disease (CKD). Reporting on the incidence of all cause stroke and major bleeding after switching from warfarin to apixaban in patients with prevalent atrial fibrillation (AF) and CKD are limited. Methods: Individuals with stage 4-5 CKD not on dialysis and prevalent non valvular AF on warfarin who switched to apixaban were identified from the United States Data Renal System from Jan 1,2012-Dec 31, 2015. The incidences of combined all cause stroke, transient ischemic attack, or systemic thromboembolism and major bleeding events were estimated. Outcomes were compared between individuals switching to apixaban and continuing on warfarin using logistic regression and survival analyses adjusted with inverse probability treatment weighting. Individuals were censored at anticoagulation discontinuation, discontinuous Medicare part D, dialysis, kidney transplant, a 2 nd switch in anticoagulant, or death. Results: 1762 individuals with advanced CKD with AF were on warfarin; 71 (4.0%) switched to apixaban (57.8% male, mean age 78.2 years (SD ±6.6), 78.9% white, mean CHA 2 DS 2 -VASc 5.0 (SD ±1.5), mean HAS-BLED 2.2 (SD ±0.5) and 1691 (41.3%) continued warfarin (47.6% male, mean age 80.1 years (SD ±8.7), 87.9% white, mean CHA 2 DS 2 -VASc 5.5 (SD ±1.6), mean HAS-BLED 2.5 (SD ±0.8). Incidence of all cause stroke in the apixaban switch and warfarin continuation groups were 0.020/patient year (95%CI 0.002- 0.123) and 0.061/patient year (95%CI 0.054-0.068) (p=0.211). Incidence of major bleeding in the two groups were 0.018/patient year (95% CI 0.002 - 0.125) and 0.045 (95% CI 0.033 - 0.044) (p =0.438). The risk of all cause stroke (OR 0.06; 95% CI 0.01-0.45; HR 0.18 (95%CI 0.03-1.35)) and major bleeding (OR 0.09; 95%CI 0.01-0.68; HR is 0.31 95%CI (0.04-2.27)) were lower in the apixaban switch compared to the warfarin continuation group. Conclusions: The incidence and risk of all cause stroke and major bleeding are lower in individuals with stage4-5 CKD and prevalent AF who switch from warfarin to apixaban versus continuing on warfarin. Data are limited by few events and short duration on apixaban.

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Interatrial block, P terminal force or fragmented QRS do not predict new-onset atrial fibrillation in patients with severe chronic kidney disease

BMC Cardiovascular Disorders ◽

10.1186/s12872-020-01719-3 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Tapio Hellman ◽

Markus Hakamäki ◽

Roosa Lankinen ◽

Niina Koivuviita ◽

Jussi Pärkkä ◽

...

Keyword(s):

Atrial Fibrillation ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

P Wave ◽

Stage 4 ◽

Ckd Stage ◽

Severe Chronic Kidney Disease ◽

Onset Atrial Fibrillation ◽

New Onset

Abstract Background The prevalence of left atrial enlargement (LAE) and fragmented QRS (fQRS) diagnosed using ECG criteria in patients with severe chronic kidney disease (CKD) is unknown. Furthermore, there is limited data on predicting new-onset atrial fibrillation (AF) with LAE or fQRS in this patient group. Methods We enrolled 165 consecutive non-dialysis patients with CKD stage 4–5 without prior AF diagnosis between 2013 and 2017 in a prospective follow-up cohort study. LAE was defined as total P-wave duration ≥120 ms in lead II ± > 1 biphasic P-waves in leads II, III or aVF; or duration of terminal negative portion of P-wave > 40 ms or depth of terminal negative portion of P-wave > 1 mm in lead V1 from a baseline ECG, respectively. fQRS was defined as the presence of a notched R or S wave or the presence of ≥1 additional R waves (R’) or; in the presence of a wide QRS complex (> 120 ms), > 2 notches in R or S waves in two contiguous leads corresponding to a myocardial region, respectively. Results Mean age of the patients was 59 (SD 14) years, 56/165 (33.9%) were female and the mean estimated glomerular filtration rate was 12.8 ml/min/1.73m2. Altogether 29/165 (17.6%) patients were observed with new-onset AF within median follow-up of 3 [IQR 3, range 2–6] years. At baseline, 137/165 (83.0%) and 144/165 (87.3%) patients were observed with LAE and fQRS, respectively. Furthermore, LAE and fQRS co-existed in 121/165 (73.3%) patients. Neither findings were associated with the risk of new-onset AF within follow-up. Conclusion The prevalence of LAE and fQRS at baseline in this study on CKD stage 4–5 patients not on dialysis was very high. However, LAE or fQRS failed to predict occurrence of new-onset AF in these patients.

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Reclassification, Thromboembolic, and Major Bleeding Outcomes Using Different mates of Renal Function in Anticoagulated Patients With Atrial Fibrillation: Insights From the PREFER-in-AF and PREFER-in-AF Prolongation Registries

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.120.006852 ◽

2021 ◽

Author(s):

Miklos Rohla ◽

Ladislav Pecen ◽

Roberto Cemin ◽

Giuseppe Patti ◽

Jolanta M. Siller-Matula ◽

...

Keyword(s):

Atrial Fibrillation ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Dose Reduction ◽

Major Bleeding ◽

Odds Ratio ◽

Thromboembolic Events ◽

Bleeding Events ◽

Disease Epidemiology ◽

Anticoagulated Patients

Background: The Cockcroft-Gault formula is recommended to determine a renal indication for dose reduction of dabigatran, edoxaban, and rivaroxaban. Nephrology guidelines now recommend the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulae as more accurate estimates of glomerular filtration rate. Methods: We analyzed anticoagulated patients with atrial fibrillation who were enrolled in the Prevention of Thromboembolic Events – European Registry in Atrial Fibrillation (PREFER in AF). The proportion of patients with dissimilar renal dosing indications was assessed when applying Cockcroft-Gault, MDRD, or CKD-EPI. Thromboembolic and major bleeding events at 1 year were compared in patients in whom Cockcroft-Gault and CKD-EPI provided concordant or discordant results around a threshold of 50 mL/minute. Results: Out of 1288 patients with atrial fibrillation with chronic kidney disease in whom Cockcroft-Gault suggested a dose reduction of dabigatran, edoxaban, or rivaroxaban (creatinine clearance ≤50 mL/minutes), 19% and 16% were reclassified to the respective higher doses, and 24% and 23% to the respective lower doses by applying the MDRD and CKD-EPI formulae, respectively. In patients potentially receiving a different dose of dabigatran, edoxaban, or rivaroxaban when using CKD-EPI, we observed an excess of thromboembolic events (4.1% versus 0.8%; odds ratio, 5.5 [95% CI, 1.5–20.8]; P =0.01). Major bleeding rates were nonsignificantly different in the discordance versus concordance group (5.7% versus 2.7%; odds ratio, 2.2 [95% CI, 0.9–5.6]; P =0.09). Conclusions: The MDRD and CKD-EPI formulae suggest a different dosing in up to a quarter of anticoagulated patients with atrial fibrillation. This seems to impact hard outcomes.

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Abstract 16043: Effectiveness and Safety of Switching From Warfarin to Apixaban in Advanced Chronic Kidney Disease Patients With Prevalent Atrial Fibrillation in the United States Between 2012 and 2016

Circulation ◽

10.1161/circ.142.suppl_3.16043 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Katherine Garlo ◽

Thomas Mavrakanas ◽

Elisabeth Burdick ◽

Wei Wang ◽

David Charytan

Keyword(s):

United States ◽

Major Bleeding ◽

The United States ◽

Bleeding Events ◽

Part D ◽

Safety Outcome ◽

Efficacy Outcome ◽

Major Bleeding Events ◽

Ischemic Attack ◽

Direct Acting

Introduction: Apixaban is the preferred direct acting oral anticoagulant in patients with CKD and has advantages compared with warfarin. Data on effectiveness and safety outcomes after switching from warfarin to apixaban in patients with prevalent AF and CKD are limited. Methods: Individuals with advanced CKD not on dialysis and prevalent AF who receive ≥6 months of continuous warfarin prior to Jan 1, 2012 were identified from the United States Data Renal System (USRDS) database. Individuals were followed from Jan 1, 2012 - Dec 31, 2015 to identify switches from warfarin to apixaban. The primary efficacy outcome was combined all-cause stroke, transient ischemic attack, or systemic thromboembolism. The primary safety outcome was major bleeding. Outcomes were compared between patients switching from apixaban and those continuing warfarin. Individuals were censored at the time of the first event or anticoagulation discontinuation, discontinuous Medicare part D coverage, dialysis, kidney transplant, a 2 nd switch in anti-coagulant, or death. Results: 1762 individuals with advanced CKD not receiving dialysis with non valvular AF or flutter were on warfarin during the 6 months prior to Jan 1, 2012. Of these, 71 (4.0%; 57.8% male, mean age 78.2 years (SD ±6.6), 78.9% white) switched from warfarin to apixaban and 1691 (41.3%; 47.6% male, mean age 80.1 years (SD ±8.7), 87.9% white) continued warfarin from Jan 1, 2012 - Dec 31, 2015. Incidence of all cause stroke or systemic thromboembolism in the apixaban switch and warfarin continuation groups were 1 (1.4%) and 303 (17.8%) respectively. Incidence of major bleeding events in the two groups were 1 (1.4%) and 201 (11.9%). Conclusions: Among advanced CKD patients with AF in the US who switched from warfarin to apixaban the proportion of all cause stroke or systemic thromboembolism and major bleeding events were low. Data is limited by duration of apixaban market authorization and short follow up.

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Elevated Troponin T and enlarged left atrium predict the incidence of atrial fibrillation in patients with chronic kidney disease stage 4-5

10.21203/rs.3.rs-28001/v1 ◽

2020 ◽

Author(s):

Markus Hakamäki ◽

Tapio Hellman ◽

Roosa Lankinen ◽

Niina Koivuviita ◽

Jussi Pärkkä ◽

...

Keyword(s):

Atrial Fibrillation ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Troponin T ◽

Volume Index ◽

Elevated Troponin ◽

Stage 4 ◽

Ckd Stage ◽

New Onset

Abstract Background Atrial fibrillation (AF) and chronic kidney disease (CKD) are commonly co-existing conditions. However, data on epidemiology of AF in patients with CKD stage 4–5 is scarce. Methods We prospectively enrolled 210 consecutive non-dialysis patients with CKD stage 4–5 between 2013 and 2017. Follow-up data on AF incidence along with medical history, laboratory tests and echocardiography at baseline were gathered. Results At baseline, mean age was 62 years, estimated glomerular filtration rate 12.8 ml/min and 73/210 (34.8%) of the participants were female. Altogether 41/210 (19.5%) patients had a previous diagnosis of AF. After median follow-up of 46 [IQR 27] months, new-onset AF occurred in 33/169 (19.5%) patients (69.9 events/1000 person-years). Overall, 22/33 (66.7%) of patients with new-onset AF were identified with a triggering condition and 21/33 (63.6%) were receiving renal replacement therapy (dialysis or acquired kidney transplant) at the time of AF detection, respectively. In Cox proportional hazard model age > 60 years (HR 4.27, CI95% 1.57–11.64, p < 0.01), elevated troponin T (TnT) > 50 ng/l (HR 3.61, CI95% 1.55–8.37, p < 0.01) and left atrial volume index (LAVI) > 30 ml/m2 (HR 4.82, CI95% 1.11-21.00, p = 0.04) independently predicted the incidence of new-onset AF. Conclusions The prevalence and incidence of AF was markedly high in this prospective study on patients with CKD stage 4–5. Elevated TnT and increased LAVI were identified as independent predictors for new-onset AF in patients with severe CKD.

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

European Heart Journal ◽

10.1093/ehjci/ehaa946.0649 ◽

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 <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

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

European Heart Journal ◽

10.1093/ehjci/ehaa946.0673 ◽

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

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Abstract 17152: Frequency and Management of Major Bleeding in Atrial Fibrillation Patients Treated With Warfarin and Non-vitamin K Oral Anticoagulants in Community Practice: Results From the ORBIT-AF II Registry

Circulation ◽

10.1161/circ.132.suppl_3.17152 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Benjamin A Steinberg ◽

DaJuanicia N Simon ◽

Laine Thomas ◽

Jack Ansell ◽

Gregg C Fonarow ◽

...

Keyword(s):

Atrial Fibrillation ◽

Clinical Practice ◽

Vitamin K ◽

Major Bleeding ◽

Oral Anticoagulants ◽

Recurrent Bleeding ◽

Bleeding Events ◽

Reversal Agents ◽

Major Bleeding Events

Background: Non-vitamin K oral anticoagulants (NOACs) are effective at preventing stroke in patients with atrial fibrillation (AF). However, little is known about the frequency of major bleeds on NOACs and how these events are managed in clinical practice. Methods: We assessed the rates, management, and outcomes of ISTH major bleeding events among AF patients in the ORBIT-AF II registry (mean follow-up 213 days). Results: Overall, 103 patients experienced 110 major bleeding events during follow-up n=90/4986 (1.8%) on NOAC, and n=20/1320 (1.5%) on warfarin. Patients with bleeding events on NOAC were slightly younger than those on warfarin (median age 76 vs. 80; p=0.2). Among mutually-exclusive bleeding types, intracranial bleeding was more common in warfarin treated patients than NOAC-treated (15% vs 6.7%), whereas GI bleeding was more common on NOACs (56% vs. 40%, overall p=0.1 for bleeding type). Management of bleeding differed by anticoagulation type: blood products and reversal agents were more commonly used in patients on warfarin (Table). No patient received prothrombin complexes, recombinant factor VIIa, aminocaproic acid, tranexamic acid, aprotinin, or desmopressin. Out of 90 major bleeding events in NOAC patients, only 1 was fatal (1%). Within 30 days following bleeding, there were no strokes and 1 TIA (NOAC). Following a major bleed, the recurrent bleeding rate in NOAC patients in the next 30-days was 4% and the death rate was 4%. Conclusions: Rates of major bleeding with NOACs in clinical practice are comparable to those reported in clinical trials. Compared with warfarin, bleeding among NOAC users was less likely intracranial and more likely to be GI. Management of bleeding in the setting of NOAC rarely includes reversal agents.

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Non-vitamin K antagonist oral anticoagulants vs. vitamin-K antagonists in patients with atrial fibrillation and chronic kidney disease: a nationwide cohort study

Thrombosis Journal ◽

10.1186/s12959-019-0211-y ◽

2019 ◽

Vol 17 (1) ◽

Cited By ~ 2

Author(s):

Emma Kirstine Laugesen ◽

Laila Staerk ◽

Nicholas Carlson ◽

Anne-Lise Kamper ◽

Jonas Bjerring Olesen ◽

...

Keyword(s):

Atrial Fibrillation ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Vitamin K ◽

Major Bleeding ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

All Cause Mortality ◽

Comparable Population

Abstract Background We aimed to compare effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) versus vitamin-K antagonists (VKA) in atrial fibrillation (AF) patients with chronic kidney disease (CKD) not receiving dialysis. Methods By using personal identification numbers, we cross-linked individual-level data from Danish administrative registries. We identified every citizen with a prior diagnosis of AF and CKD who initiated NOAC or VKA (2011–2017). An external analysis of 727 AF patients with CKD (no dialysis) was performed to demonstrate level of kidney function in a comparable population. Study outcomes included incidents of stroke/thromboembolisms (TEs), major bleedings, myocardial infarctions (MIs), and all-cause mortality. We used Cox proportional hazards models to determine associations between oral anticoagulant treatment and outcomes. Results Of 1560 patients included, 1008 (64.6%) initiated VKA and 552 (35.4%) initiated NOAC. In a comparable population we found that 95.3% of the patients had an estimated glomerular filtration rate (eGFR) < 59 mL/min. Patients treated with NOAC had a significantly decreased risk of major bleeding (hazard ratio (HR): 0.47, 95% confidence interval (CI): 0.26–0.84) compared to VKA. There was not found a significant association between type of anticoagulant and risk of stroke/TE (HR: 0.83, 95% CI: 0.39–1.78), MI (HR: 0.45, 95% CI: 0.18–1.11), or all-cause mortality (HR: 0.99, 95% CI: 0.77–1.26). Conclusion NOAC was associated with a lower risk of major bleeding in patients with AF and CKD compared to VKA. No difference was found in risk of stroke/TE, MI, and all-cause mortality.

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Chronic kidney disease and undiagnosed atrial fibrillation in individuals with diabetes

Cardiovascular Diabetology ◽

10.1186/s12933-020-01128-y ◽

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.

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