Why the study?
Do oral anticoagulants (warfarin and NOACs) improve stroke or bleeding outcomes in patients with atrial fibrillation and stage 4-5 chronic kidney disease?
Do oral anticoagulants (warfarin and NOACs) improve stroke or bleeding outcomes in patients with atrial fibrillation and stage 4-5 chronic kidney disease?
In a large U.S. cohort of patients with atrial fibrillation and advanced chronic kidney disease, the majority are not treated with oral anticoagulants, highlighting ongoing uncertainty in clinical practice.
Clause 1 (Clinical): Highlights massive clinical uncertainty/underutilization in advanced CKD.
Background: Oral anticoagulants (OAC) reduce the risk of stroke but impose the risk of bleeding in patients with atrial fibrillation (AF). In the setting of advanced chronic kidney disease (CKD), the overall net benefit of OAC remains controversial. Purpose: Since patients with advanced CKD were excluded from recent pivotal trials of non-vitamin K antagonist oral anticoagulants (NOACs), we aimed to investigate the use and outcomes of warfarin and NOACs in patients with advanced CKD managed in contemporary routine clinical practice. Methods: Using a large U.S. administrative database, we identify 49,953 patients with AF and stage 4–5 CKD between 10/1/2010–1/31/2016. We used Cox proportional hazards models to assess the relationships between drug exposure and stroke or bleeding outcomes, adjusting for propensity scores calculated based on 59 socio-demographic and clinical characteristics. Results: Two-thirds of the patients were not treated with OAC, and a substantial minority (28%) were treated with warfarin. Outcomes were illustrated in the figure and remained unchanged if considering death as a competing risk or using other propensity score methods.
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Noseworthy et al. (2017) studied this question.
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