Meta-Analysis of Anticoagulation Use, Stroke, Thromboembolism, Bleeding, and Mortality in Patients With Atrial Fibrillation on Dialysis

Wong, Christopher X.; Odutayo, Ayodele; Emdin, Connor A.; Kinnear, Ned; Sun, Michelle T.

doi:10.1016/j.amjcard.2016.03.042

Cited by 26 publications

(25 citation statements)

References 44 publications

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“…The associations between OAC use and lower mortality rates in this population of patients with CKD and NVAF are largely consistent with findings of other large population-based cohorts [10, 12, 30, 32]. However, recent meta-analyses of observational studies on oral anticoagulation in comorbid CKD and AF suggest that while patients with lower stages of CKD might benefit from OAC use, patients with ESRD showed no association between OAC use and reduced mortality or stroke risk [14, 33]. Studies also reported mixed findings for OAC use and prevention of ischemic stroke in NVAF and CKD patients, with some studies reporting a decrease in stroke risk with OAC use [10, 32, 34] while others report no association or even an increased risk of ischemic stroke [12, 30, 33].…”

Section: Discussionsupporting

confidence: 87%

“…However, recent meta-analyses of observational studies on oral anticoagulation in comorbid CKD and AF suggest that while patients with lower stages of CKD might benefit from OAC use, patients with ESRD showed no association between OAC use and reduced mortality or stroke risk [14, 33]. Studies also reported mixed findings for OAC use and prevention of ischemic stroke in NVAF and CKD patients, with some studies reporting a decrease in stroke risk with OAC use [10, 32, 34] while others report no association or even an increased risk of ischemic stroke [12, 30, 33]. In our study, those receiving warfarin or DOACs were less likely to die in the 90 days to 1 year after NVAF diagnosis, and were less likely to experience any hospitalization, MI, or ischemic stroke.…”

Section: Discussionmentioning

confidence: 99%

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Clinical outcomes and treatment patterns among Medicare patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease

Wilson

Luo

et al. 2019

PLoS ONE

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BackgroundPatients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease (CKD) have increased risk of adverse outcomes. This study evaluated treatment with oral anticoagulants and outcomes in elderly NVAF patients with CKD.MethodsRetrospective observational cohort study of US Medicare fee-for-service patients aged ≥66 years with comorbid CKD (advanced: Stage 4 and higher; less advanced: Stages 1–3) and a new NVAF diagnoses from 2011–2013. All-cause mortality, stroke, major bleeding, and myocardial infarction rates were estimated for 1 year post-NVAF diagnosis. Associations between CKD stage and outcomes were evaluated with multivariate-adjusted Cox regression. We assessed oral anticoagulant (OAC) receipt within 90 days post-NVAF diagnosis and associations between OAC receipt and outcomes.ResultsThere were 198,380 eligible patients (79,681 with advanced CKD). After adjustment for age, gender, and comorbidities, advanced CKD was associated with increased mortality (Stage 5 HR 1.47; 95% CI 1.42–1.52), MI (HR 1.48; 95% CI 1.33–1.64), stroke (HR 1.23; 95% CI 1.11–1.37) and major bleed (HR 1.44; 95% CI 1.36–1.53) risks. Among Medicare Part D enrollees who survived ≥90 days post-NVAF diagnosis, 65–71% received no OACs in the first 90 days. Those receiving warfarin (HR 0.73; 95% CI 0.71–0.75) or DOACs (HR 0.52; 95% CI 0.49–0.56) within the first 90 days had reduced mortality in the period 90 days to 1 year following NVAF diagnosis compared to those without.ConclusionElderly NVAF patients with advanced CKD (Stage 4 or higher) had higher mortality risks and serious clinical outcomes than those with less advanced CKD (Stage 1–3). OAC use was low across all CKD stages, but was associated with a lower mortality risk than no OAC use in the first year post-NVAF diagnosis.

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Section: Discussionsupporting

confidence: 87%

Section: Discussionmentioning

confidence: 99%

Clinical outcomes and treatment patterns among Medicare patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease

Wilson

Luo

et al. 2019

PLoS ONE

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“…37 In light of these results from nonrandomized studies, the overall efficacy and safety of warfarin or other vitamin K antagonists for stroke prevention in AF in the HD setting is not confirmed. 38,39 The emergence of DOACs as new treatment options for stroke prevention in AF raised hope that new evidence in the setting of patients with ESRD with AF would become available. The hope that the trials of DOACs for stroke prevention in AF would include patients with ESRD was not fulfilled.…”

Section: Stroke Prevention In Patients With Atrial Fibrillation On mentioning

confidence: 99%

Atrial fibrillation in patients with end‐stage renal disease on hemodialysis: Magnitude of the problem and new approach to oral anticoagulation

Königsbrügge

2019

Research and Practice in Thrombosis and Haemostasis

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Atrial fibrillation (AF) is a frequent comorbid condition in patients with end‐stage renal disease on hemodialysis (HD) with a prevalence of up to 27%. The incidence rate of stroke in AF patients on HD is approximately 5%. The AF‐associated risk of stroke is a major clinical challenge because current evidence for anticoagulation in HD patients with AF is based on observational data. Results from these observational studies is largely contradictory because they do not show a clear benefit of vitamin K antagonists over no treatment in terms of stroke prevention, and they show an increased risk of hemorrhage associated with anticoagulation treatment in HD patients. HD patients were not included in randomized trials of the direct oral anticoagulants (DOACs), and therefore there is no evidence to support efficacy and safety of DOACs compared to vitamin K antagonists in HD patients. The pharmacological characteristics of DOACs are of particular interest in the HD setting. The factor Xa inhibitors rivaroxaban, apixaban, and edoxaban are not predominantly eliminated via the kidneys. The thrombin inhibitor dabigatran is 80% eliminated via the kidneys but is dialyzable due to its low protein binding. In this narrative review, we examine the current state of evidence regarding the prevalence of AF in patients on HD, the associated risk of stroke, and the efficacy and safety of anticoagulation for stroke prevention in the HD setting. Further, based on the pharmacokinetic properties of DOACs, we discuss their potential use in patients on HD and ongoing randomized trials.

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“…Patienten mit eingeschränkter Nierenfunktion liegen unter Therapie mit Vitamin-K-Antagonisten seltener im therapeutischen INR-Bereich als Patienten mit normaler Nierenfunktion [37,38]. Behandlung mit Warfarin reduziert bei Patienten mit Vorhofflimmern und schwerer Niereninsuffizienz das Schlaganfallrisiko nur moderat, erhöht aber das Risiko schwerer Blutungen [38][39][40][41] und hat keinen Einfluss auf die Überlebensrate [38].…”

Section: Niereninsuffizienz Einfluss Auf Die Nierenfunktionunclassified

Gerinnungshemmende Therapie

Dempfle¹

2018

Klinikarzt

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ZusammenfassungEine gerinnungshemmende Therapie mit Vitamin-K-Antagonisten erfordert eine individuelle Dosisfindung und eine ständige Therapiekontrolle.Die Wirkdauer insbesondere von Phenprocoumon ist mit bis zu 21 Tagen sehr lang und nicht vorhersehbar und verkürzt sich nach Vitamin-K-Gabe auf 2 Tage, es besteht ein erhebliches Blutungsrisiko und der Schweregrad der Blutungen ist in der Regel höher als bei vergleichbaren Blutungen unter direkten oralen Antikoagulanzien (DOAK). Für operative Eingriffe müssen Vitamin-K-Antagonisten meist abgesetzt werden, die Empfehlungen einer präoperativen 5-tägigen Therapiepause ohne Überbrückung durch ein niedermolekulares Heparin für Warfarin sind auf Phenprocoumon nicht übertragbar. Bei Absetzen von DOAK wird eine normale Hämostasefunktion hingegen in der Regel innerhalb von 24–48 Stunden erreicht. Längerfristige Behandlung mit Vitamin-K-Antagonisten führt häufig zu Osteoporose und vermehrter Atherosklerose, sowie zu zunehmender Beeinträchtigung der Nierenfunktion, Effekte, die unter DOAK nicht beobachtet werden.Spezielle Probleme für Vitamin K-Antagonisten ergeben sich bei Patienten mit Antiphospholipid-Syndrom, Protein C-Mangel, Protein S-Mangel oder Faktor VII-Mangel. Für eine bevorzugte Verwendung von DOAK sprechen rascher Wirkbeginn, kurze und vorhersehbare Wirkdauer bei standardisierter Dosierung, weniger und weniger schwere Blutungen, wesentlich einfacheres perioperatives Management und Vermeidung von Osteoporose und anderen Folgen der Vitamin-K-Antagonisten. Für die zugelassenen Indikationen haben DOAK daher etliche Vorteile im Vergleich zu den Vitamin-K-Antagonisten. Es ist aber zu berücksichtigen, dass auch bei Verwendung von DOAK eine gewissenhafte ärztliche Patientenführung nötig ist und die DOAK für einige Indikationen nicht zugelassen sind.

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Meta-Analysis of Anticoagulation Use, Stroke, Thromboembolism, Bleeding, and Mortality in Patients With Atrial Fibrillation on Dialysis

Cited by 26 publications

References 44 publications

Clinical outcomes and treatment patterns among Medicare patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease

Clinical outcomes and treatment patterns among Medicare patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease

Atrial fibrillation in patients with end‐stage renal disease on hemodialysis: Magnitude of the problem and new approach to oral anticoagulation

Gerinnungshemmende Therapie

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