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Anticoagulation use in older patients with AF, CKD confers mixed outcomes
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Among older patients with atrial fibrillation and chronic kidney disease, anticoagulation use was linked to increased risk for ischemic stroke and hemorrhage but decreased risk for mortality, researchers reported.
“Chronic kidney disease is common among older people, and one in three affected also have atrial fibrillation,” Shankar Kumar, BSc(Hons), MBBS, from the Centre for Medical Imaging, University College London, said in a press release. “We found that in this particular group, their medication seems to do the opposite of its intended effect.”
The researchers conducted a propensity-matched, population-based retrospective cohort study of patients aged at least 65 years (mean age, 82 years; 55% women) with newly diagnosed AF and chronic kidney disease (CKD), defined as estimated glomerular filtration rate less than 50 mL/min/173 m2.
For the analysis, 2,434 patients who received a prescription for an anticoagulant within 60 days of AF diagnosis were matched with 2,434 who did not. Patients were followed for a median of 506 days (interquartile range, 175-1,311). The outcomes of interest were ischemic stroke, cerebral or gastrointestinal hemorrhage and mortality.
During the study period, the crude rates of ischemic stroke were 4.6 per 100 person-years in the anticoagulant group and 1.5 per 100 person-years in the no-anticoagulant group (HR = 2.6; 95% CI, 2-3.38), Kumar and colleagues wrote.
Rates of hemorrhage were 1.2 per 100-person years in the anticoagulant group and 0.4 per 100 person-years in the no-anticoagulant group (HR = 2.42; 95% CI, 1.44-4.05).
However, those prescribed an anticoagulant had a lower risk for all-cause mortality during the study period than those not prescribed one (HR = 0.82; 95% CI, 0.74-0.91), according to the researchers.
“As we found a paradoxical reduced mortality rate alongside increased rates of stroke and major bleeding, this is clearly a very complex area,” Kumar said in the release. “We strongly call for randomized controlled studies to test the clinical value and safety of anticoagulant drug therapy for people with both atrial fibrillation and chronic kidney disease.” – by Erik Swain
Disclosures: Kumar reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Jonathan P. Piccini, MD, MHS, FACC, FAHA, FHRS
Observational data are very important, but confounding is always a challenge. Only about a third of patients were anticoagulated, and it is likely that the patients differed between the two groups, including in ways that the authors did not include in their adjustment. For example, the anticoagulated/treated patients had a higher rate of aspirin use, and it may be likely that they also differed in other ways that might increase the likelihood of bleeding or having an ischemic event. This highlights the importance of randomization and future studies.
We have great data from the large direct oral anticoagulant trials that patients with moderate CKD (creatinine clearance > 30 mL/min) do well with direct oral anticoagulant therapy. However, we have little to no data with direct oral anticoagulants in patients with severe CKD, and therefore we prevent stroke with warfarin in these patients.
Like all good research, these data raise more questions than answers. More and more data highlight the need for a randomized study of stroke prevention in AF complicated by severe CKD. Given the high risks for bleeding in patients with CKD, we really need a large trial of left atrial appendage occlusion versus direct-acting oral anticoagulant therapy.
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