Stroke and Bleeding in Atrial Fibrillation with Chronic Kidney Disease

Olesen, Jonas Bjerring; Lip, Gregory Y.H.; Kamper, Anne-Lise; Hommel, Kristine; Køber, Lars; Lane, Deirdre A.; Lindhardsen, Jesper; Gislason, Gunnar; Torp‐Pedersen, Christian

doi:10.1056/nejmoa1105594

Cited by 820 publications

(814 citation statements)

References 27 publications

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“…Our finding of an increased risk of ischaemic stroke in patients with CKD‐no RRT is similar to previous findings from non‐HF populations 9, 25. As the aim of our study was to examine the prognostic value of CKD in relation to stroke, major bleeding, and mortality in HF, we can only speculate on the aetiological explanations for our observations.…”

Section: Discussionsupporting

confidence: 90%

“…Patients with CKD were identified using ICD‐10 codes in the Danish registries, which have also been used in previous registry‐based studies of patients with CKD 9, 25. However, we did not have access to biomarkers, and therefore, CKD could be under‐reported, as a measurement outside normal ranges might not necessarily trigger a diagnosis in the registries.…”

Section: Discussionmentioning

confidence: 99%

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Risk of stroke and bleeding in patients with heart failure and chronic kidney disease: a nationwide cohort study

et al. 2018

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AimsThe aim of this study was to assess the prognostic value of chronic kidney disease (CKD) in relation to ischaemic stroke, intracranial haemorrhage, major bleeding, and all‐cause death in heart failure patients without atrial fibrillation.Methods and resultsIn this observational cohort study, heart failure patients without atrial fibrillation were identified using Danish nationwide registries. Risk of stroke, major haemorrhage, and death were calculated after 1 and 5 years to compare patients with and without CKD, ±dialysis [dialysis: CKD with renal replacement therapy (CKD‐RRT); no dialysis: CKD‐no RRT]. A total of 43 199 heart failure patients were included, among which 0.8% had CKD‐RRT and 5.9% had CKD‐no RRT. When compared with heart failure patients without CKD, both CKD‐RRT and CKD‐no RRT were associated with a higher 5 year rate of major bleeding (CKD‐RRT: adjusted hazard ratio (aHR): 2.91, 95% confidence interval (CI): 2.29 to 3.70; CKD‐no RRT: aHR: 1.28, 95% CI: 1.13 to 1.45) and all‐cause death (CKD‐RRT: aHR: 2.40, 95% CI: 2.07 to 2.77; CKD‐no RRT: aHR: 1.63, 95% CI: 1.55 to 1.73). For the endpoints of ischaemic stroke and intracranial bleeding, only CKD‐no RRT was associated with significantly higher 5 year rates (ischaemic stroke: aHR: 1.31, 95% CI: 1.13 to 1.52; intracranial haemorrhage: aHR: 1.66, 95% CI: 1.04 to 2.65).ConclusionsCompared with patients without CKD, among incident heart failure patients without atrial fibrillation, CKD both with and without dialysis was associated with a higher rate of major bleeding and all‐cause death. Only CKD‐no RRT was associated with a higher rate of ischaemic stroke and intracranial bleeding.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Risk of stroke and bleeding in patients with heart failure and chronic kidney disease: a nationwide cohort study

et al. 2018

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“…Three analyses identified an association between warfarin use and increased risk for bleeding and embolic stroke,11, 12, 13 while the fourth analysis associated warfarin use with an increased risk of bleeding and a decreased risk of stroke or systemic embolism 14. In the present analysis, a trend towards increased bleeding as well as all‐cause stroke, systemic embolism, or TIA was observed in patients with Stage IV or V CKD treated with an OAC compared with patients without CKD that received an OAC.…”

Section: Discussionmentioning

confidence: 99%

Pharmacotherapy for Atrial Fibrillation in Patients With Chronic Kidney Disease: Insights From ORBIT‐AF

Washam

Holmes

Thomas

et al. 2018

JAHA

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BackgroundChronic kidney disease (CKD) is a common comorbidity in patients with atrial fibrillation. The presence of CKD complicates drug selection for stroke prevention and rhythm control.Methods and ResultsPatients enrolled in ORBIT AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation) with baseline renal function and follow‐up data were included (N=9019). CKD was defined as an estimated creatinine clearance <60 mL/min. Patient characteristics were compared by CKD status, and Cox proportional hazards modeling was used to examine the association between oral anticoagulant (OAC) use and outcomes and antiarrhythmic drug use and outcomes stratified by CKD stages. At enrollment, 3490 (39%) patients had an estimated creatinine clearance <60 mL/min. Patients with CKD were older and had higher CHA 2 DS 2 VASc and Anticoagulant and Risk Factors in Atrial Fibrillation (ATRIA) scores. A rhythm control strategy was selected less frequently in patients with CKD, while OAC use was lower among Stage IV and V CKD patients. After adjustment, no significant interaction was noted for OAC and CKD on all‐cause mortality (P=0.5442) or cardiovascular death (P=0.1233), although a trend for increased major bleeding (P=0.0608) and stroke, systemic embolism or transient ischemic attack (P=0.0671) was observed. No interaction was noted for antiarrhythmic drug use and CKD status on all‐cause mortality (P=0.9706), or stroke, systemic embolism or transient ischemic attack (P=0.4218).ConclusionsPatients with atrial fibrillation and CKD are less likely to be treated with rhythm control. Patients with advanced CKD are less likely to receive OAC. Finally, outcomes with OAC in patients with advanced CKD may be materially different with higher rates of both bleeding and stroke.

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“…W dużych bazach danych występowanie CKD wiąże się z udarami i krwawieniami [410,411]. Leczenie przeciwzakrzepowe można bezpiecznie stosować u pacjentów z umiarkowaną i umiarkowanie ciężką CKD ([współczynnik przesączania kłębuszkowego (GFR) ≥ 15 ml/min]: CKD w 3. stadium (oszacowany GFR < 59 ml/min/1,73 m 2 ) występowała u 805 spośród 1936 pacjentów objętych randomizacją w badaniu Stroke Prevention in Atrial Fibrillation (SPAF) i w tej grupie uzyskano dobre efekty leczenia warfaryną (INR 2-3) [412].…”

Section: Doustne Leczenie Przeciwzakrzepowe U Pacjentów Z Migotaniem unclassified

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

Kirchhof

Benussi

Kotecha³

et al. 2016

Kardiol Pol

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4,206

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Stroke and Bleeding in Atrial Fibrillation with Chronic Kidney Disease

Cited by 820 publications

References 27 publications

Risk of stroke and bleeding in patients with heart failure and chronic kidney disease: a nationwide cohort study

Risk of stroke and bleeding in patients with heart failure and chronic kidney disease: a nationwide cohort study

Pharmacotherapy for Atrial Fibrillation in Patients With Chronic Kidney Disease: Insights From ORBIT‐AF

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

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