Oral anticoagulation may be harmful in AF, end-stage renal disease
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The use of oral anticoagulation was low and may not be safe or effective in patients with atrial fibrillation and end-stage renal disease, according to a retrospective study of a propensity-matched cohort published in the Journal of the American College of Cardiology.
The study found no link between oral anticoagulation — either warfarin or a direct oral anticoagulant — and reduced risk for death and stroke, although there was an association with its use and increased risk for hospitalization for intracranial hemorrhage or bleeding.
“Outcomes guidelines caution against routine oral anticoagulation, while the 2014 ACC/AHA/HRS guidelines provide a grade IIa recommendation for use of warfarin in ESRD,” Cardiology Today Editorial Board Member Jonathan P. Piccini, MD, associate professor of medicine and director of the Duke Center for Atrial Fibrillation at Duke University Medical Center, told Healio. “Our analysis confirms and extends prior reports in a contemporary nationwide analysis.”
Medicare fee-for-service claims
Sean D. Pokorney, MD, MHS, assistant professor of medicine in the department of cardiology at Duke University School of Medicine and member of the Duke Clinical Research Institute, and colleagues analyzed a 5% sample of Medicare fee-for-service claims data including 8,410 patients with AF and end-stage renal disease (ESRD) from 2006 to 2013.
Information assessed in this study included baseline comorbidities, characteristics, dialysis type and medications. Patients were categorized in the oral anticoagulant group if they filled at least one prescription for dabigatran (Pradaxa, Boehringer Ingelheim), apixaban (Eliquis, Bristol-Myers Squibb/Pfizer), warfarin or rivaroxaban (Xarelto, Janssen/Bayer) during the study period.
Of the patients in this study, 36.2% were treated with oral anticoagulation.
Propensity score methods were used to match patients with AF and ESRD on oral anticoagulation (n = 1,519) with those with AF and ESRD without oral anticoagulation (n = 3,018).
Oral anticoagulation use was not associated with reduced risk for death (HR = 1.02; 95% CI, 0.94-1.1) or hospitalization for stroke (HR = 1; 95% CI, 0.82-1.23). In contrast, oral anticoagulation use was associated with increased risk for hospitalization for intracranial hemorrhage (adjusted HR = 1.3; 95% CI, 1.07-1.59) and for bleeding (aHR = 1.26; 95% CI, 1.09-1.46).
“The major clinical implication is that we need alternative stroke prevention strategies in patients with AF and ESRD,” Piccini said in an interview. “One potential treatment option that may not lead to increased risks of bleeding is a nonpharmacologic option like percutaneous left atrial appendage occlusion/closure (LAAO). Left atrial appendage occlusion should be tested in a clinical trial to see if LAAO reduces stroke effectively in patients with AF and ESRD.”
More monitoring efforts
In a related editorial, Jonas Bjerring Olesen, MD, PhD, associate professor in the department of cardiology at University of Copenhagen, and Anders Nissen Bonde, MD, PhD, also from the University of Copenhagen, wrote: “It remains to be determined if warfarin is associated with a positive or negative net clinical benefit in patients with atrial fibrillation and severe chronic kidney disease, especially in end-stage renal disease. Thus, it seems clear that well-controlled warfarin treatment is difficult to achieve in these patients, and when warfarin is chosen, more efforts should be put into monitoring of the patient than usual.” – by Darlene Dobkowski
For more information:
Jonathan P. Piccini, MD, can be reached at jonathan.piccini@duke.edu; Twitter: @jonpiccinisr.
Disclosures: Pokorney reports he received research grants from Boston Scientific, Bristol-Myers Squibb, Gilead, Janssen Pharmaceuticals and Pfizer; received consultant and research support from Boston Scientific, Bristol-Myers Squibb, Janssen Pharmaceuticals, Medtronic and Pfizer; research support from the FDA, and speakers bureau support from Zoll. Olesen reports he served as a speaker for Bayer, Boehringer Ingelheim, Bristol-Myers Squibb and Pfizer; consulted for Boehringer Ingelheim, Bristol-Myers Squibb, Novartis Healthcare and Novo Nordisk, and received research funding from Bristol-Myers Squibb and The Capital Region of Denmark Foundation for Health Research. Piccini reports he received clinical research grants from Abbott, the American Heart Association, the Association for the Advancement of Medical Instrumentation, Bayer, Boston Scientific and Philips and consulted for Abbott, Allergan, ARCA Biopharma, Biotronik, Boston Scientific, LivaNova, Medtronic, Milestone, Myokardia, Philips, Sanofi and Up-to-Date. Bonde reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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