Chronic kidney disease and cardiovascular mortality in patients with atrial fibrillation

Abstract

Our aim was to analyze characteristics of atrial fibrillation (AF) patients with chronic kidney disease (CKD) from the Croatian cohort of the ESH A Fib survey and to determine the association of estimated glomerular filtration rate (eGFR) with cardiovascular (CV) mortality after 24 months of follow-up. Consecutive sample of 301 patients with AF were enrolled in the period 2014 to 2018. Hypertension was defined as BP > 140/90 mm Hg and/or antihypertensive drugs treatment, CKD was defined as eGFR (CKD Epi) < 60 ml/min/1.73 m2 which was confirmed after 3 months. CKD was diagnosed in 45.2% of patients (13.3% in CKD stage > 3b). CKD patients were older than non-CKD and had significantly more frequent coronary heart disease, heart failure and valvular disease. CKD patients had significantly higher CHA2DS2-VASc score and more CKD than non-CKD patients had CHA2DS2-VASc > 2. Crude CV mortality rate per 1000 population at the end of the first year of the follow-up was significantly higher in CKD vs non-CKD group who had shorter mean survival time. CV mortality was independently associated with eGFR, male gender, CHA2DS2VASc and R2CHA2DS2VASc scores. Prevalence of CKD, particularly more advanced stages of CKD, is very high in patients with AF. Observed higher CV mortality and shorter mean survival time in CKD patients could be explained with higher CHA2DS2VASc score which is a consequence of clustering of all score components in CKD patients. However, eGFR was independently associated with CV mortality. In our cohort, R2CHA2DS2VASc score was not associated significantly more with CV mortality than CHA2DS2VASc score.

Does CHA2DS2-VASc score predict mortality in chronic kidney disease?

“…Results provided evidence for the significantly better performance of GFR-based schemes—R2(GFR)CHADS2 and R2(GFR)CHA2DS2VASc—and the moderately better performance of CrCl-based schemes—R2(CrCl)CHADS2 and R2(CrCl)CHA2DS2VASc—in death risk stratification compared with CHADS2 and CHA2DS2VASc scores [ 32 ]. These findings, however, were not confirmed in a recent study by Premuzic et al The investigators sought to determine the association of eGFR with CV mortality in AF patients after 24 months of follow-up [ 33 ]. They concluded that CV mortality was independently associated with eGFR ( b = 0.169, P = 0.04), male gender ( b = 0.156, P = 0.03), CHA2DS2VASc ( b = 0.467, P = 0.02) and R2CHA2DS2VASc scores ( b = 0.391, P = 0.04) but not with R2CHADS2 score.…”

“…They concluded that CV mortality was independently associated with eGFR ( b = 0.169, P = 0.04), male gender ( b = 0.156, P = 0.03), CHA2DS2VASc ( b = 0.467, P = 0.02) and R2CHA2DS2VASc scores ( b = 0.391, P = 0.04) but not with R2CHADS2 score. In addition, R2CHA2DS2VASc was not associated with CV mortality more than CHA2DS2VASc [ 33 ].…”

Managing thrombotic risk in patients with diabetes

“…The importance of reducing renal function decline and the potential impact of the choice of anticoagulant on renal outcomes in patients with AF have also been highlighted in the 2019 update to the American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines on the management of AF, stating that ‘over time, NOACs (particularly dabigatran and rivaroxaban) may be associated with lower risks of adverse renal outcomes than warfarin in patients with AF’ [ 31 ]. This is particularly relevant in patients with AF and diabetes given the impact of worsening GFR on mortality and CV death [ 31 , 112 , 113 ]. Thus, in the context of comprehensive preventive strategies in this very vulnerable population, warfarin is not the preferred anticoagulant at an early stage in patients with diabetes, AF or in the early stages of diabetic renal disease.…”

CHA2DS2-VASc score for in-hospital recurrence risk stratification in patients with myocardial infarction

“…The optimal cutoff point of CHA 2 DS 2 -VASc was 3 and MCHA 2 DS 2 -VASc was 8 for predicting the incidence of recurrent MI, which was determined by receiver operating characteristic (ROC) curve, area under the curve (AUC) analysis, and Youden index. Patients were subsequently categorized into the low-risk group (0-2) and high-risk group (3)(4)(5)(6)(7)(8)(9) according to the CHA 2 DS 2 -VASc and low-risk group (0-7) and high-risk group (8)(9)(10)(11)(12)(13)(14)(15) according to the MCHA 2 DS 2 -VASc.…”

“…Many clinical stroke risk factors (e.g., obstructive sleep apnea, left atrium dilatation, and renal impairment) ( 6 – 8 ) as well as some biomarkers (e.g., troponin, natriuretic peptides, and von Willebrand factor) ( 9 , 10 ) are closely related to the stroke risk, but they do not improve the predictive value of CHA 2 DS 2 -VASc score. Moreover, patients with MI seem to be at increased risk for recurrent major adverse cardiovascular events (MACEs), owing to their clinical characteristics, comorbidities, and biomarkers, such as elderly (especially older women) ( 11 ), diabetes mellitus (DM), heart failure (HF), renal dysfunction ( 12 ), and interleukin-1beta ( 13 ).…”