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Oral Anticoagulants in Patients With AF and Renal Disease
Study Questions:
What are the patterns of oral anticoagulation (OAC) use in end-stage renal disease (ESRD) patients with atrial fibrillation (AF) and their associations with cardiovascular outcomes?
Methods:
The investigators analyzed treatment and outcomes in a cohort of patients with ESRD and AF using Medicare fee-for-service 5% claims data from 2007 to 2013. Prescription drug benefit information was used to determine the timing of OAC therapy. Cox proportional hazards modeling was used to compare outcomes including death, all-cause stroke, ischemic stroke, hemorrhagic stroke, and bleeding hospitalizations in ESRD patients treated with or without OAC.
Results:
The cohort included 8,410 patients with AF and ESRD. A total of 3,043 (36.2%) patients were treated with OAC at some time during the study period. Propensity scores were used to match 1,519 patients with AF and ESRD on OAC with 3,018 ESRD patients without OAC. Treatment with OAC was not associated with hospitalization for stroke (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.23-1.35; p = 0.97) or death (HR, 1.02; 95% CI, 0.94-1.10; p = 0.62). OAC was associated with an increased risk of hospitalization for bleeding (HR, 1.26; 95% CI, 1.09-1.46; p = 0.0017) and intracranial hemorrhage (HR, 1.30; 95% CI, 1.07-1.59; p = 0.0094).
Conclusions:
The authors concluded that OAC utilization was low in patients with AF and ESRD and there was no association between OAC use and reduced risk of stroke or death.
Perspective:
This nationwide analysis of patients with ESRD and AF reports that one of three patients with ESRD had AF but only one third of patients with AF, ESRD, and a CHA2DS2-VASc score ≥2 were treated with OAC. However, there was no evidence of an association between OAC therapy and lower risk of stroke. Furthermore, patients treated with OAC experienced an increased risk for all-cause bleeding and intracranial hemorrhage. It appears that optimal strategies for prevention of stroke in patients with AF and ESRD represents a major clinical need, and prospective studies of alternative treatment strategies, including target-specific oral anticoagulants and left atrial appendage occlusion, are indicated.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Brain Ischemia, Hemorrhage, Intracranial Hemorrhages, Kidney Failure, Chronic, Renal Insufficiency, Secondary Prevention, Stroke, Treatment Outcome
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