January 31, 2018ESC Heart FailureOpen Access

Risk of Stroke and Bleeding in Patients with Heart Failure and Chronic Kidney Disease: A Nationwide Cohort Study

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Why the study?

Does chronic kidney disease increase the risk of stroke, bleeding, and death in heart failure patients without atrial fibrillation?

Structured PICO

Does chronic kidney disease increase the risk of stroke, bleeding, and death in heart failure patients without atrial fibrillation?

Population

43,199 incident heart failure patients without atrial fibrillation, identified using Danish nationwide registries. 0.8% had CKD with renal replacement therapy (CKD-RRT) and 5.9% had CKD without RRT (CKD-no RRT).

Intervention

Chronic kidney disease (CKD) with or without renal replacement therapy (dialysis)

Comparator

Heart failure patients without CKD

Outcome

Ischaemic stroke, intracranial haemorrhage, major bleeding, and all-cause death at 1 and 5 yearshard clinical

In heart failure patients without atrial fibrillation, the presence of chronic kidney disease is associated with significantly increased risks of major bleeding, all-cause death, and (in non-dialysis patients) ischaemic stroke and intracranial haemorrhage.

Implication

CKD may identify higher-risk HF patients without AF; leaves open whether targeted interventions improve outcomes.

Abstract

AIMS: The 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 RESULTS: In 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). CONCLUSIONS: Compared 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.