Key result
An eGFRdiff below -10 mL/min/1.73 m2 was associated with an increased risk of major adverse cardiovascular events (HR 1.50) and heart failure hospitalization in patients with atrial fibrillation.
Why the study?
Does discordance between combined cystatin C-based and creatinine-based eGFR predict adverse cardiovascular outcomes in patients with atrial fibrillation?
Does discordance between combined cystatin C-based and creatinine-based eGFR predict adverse cardiovascular outcomes in patients with atrial fibrillation?
Hazard Ratio: 1.5
Discordance between cystatin C-based and creatinine-based eGFR identifies a high-risk cardiovascular phenotype in atrial fibrillation, though routine DOAC dosing should remain tethered to the Cockcroft-Gault equation.
BACKGROUND The Cockcroft-Gault (CG) formula remains the gold standard for renal function assessment in patients with atrial fibrillation (AF) receiving direct oral anticoagulants (DOACs), though various other estimation formulas exist. OBJECTIVE We compared the concordance and predictive performance of different renal function formulas regarding clinical outcomes in patients with AF receiving DOAC therapy. METHODS We enrolled 21,318 patients with non-valvular AF receiving DOACs between June 2012 and December 2021 from a multicenter database in Taiwan retrospectively. Renal function was estimated using eight formulas: CG, CG-BSA, MDRD, CKD-EPI, JSN-CKDI, FAS, LMR, and EKFC. Concordance was assessed utilizing weighted Cohen's Kappa. Cox regression, receiver operating characteristic (ROC) curves, and Harrell's C-index were used to evaluate their associations with clinical outcomes, defined as a composite of thromboembolism, all-cause mortality, and major bleeding. RESULTS Most patients were classified as having normal renal function (≥60 ml/min/1.73 m2 (or ml/min) across the eight renal function formulas, with proportions ranging from 25.7% using the JSN-CKDI formula to 65.3% using the CKD-EPI formula. The concordance between the CG and MDRD (K=0.512; 95%CI, 0.493-0.530) or CKD-EPI (K=0.481; 95%CI, 0.462-0.500) formula is only moderate. The risk of adverse composite outcomes increases exponentially when renal function falls below 60 ml/min/1.73 m2 (or ml/min) for the 8 formulas. Conversely, for patients with renal function values ≥60 ml/min/1.73 m2 (or ml/min), the relationship diverged across the 8 formulas. Both the MDRD (AUC:0.641;95%CI: 0.633-0.649) and CKD-EPI (AUC:0.664; 95%CI: 0.656-0.672) formulas, along with other renal function equations, demonstrated inferior discriminatory performance for predicting major adverse events compared to the CG formula (AUC:0.707; 95%CI: 0.700-0.714). CONCLUSIONS The CG formula plays a crucial role in managing Asian AF patients in the DOAC era, proving essential for both guiding dosing and predicting adverse clinical events.
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Cheng et al. (2026) conducted an editorial in Atrial fibrillation (n=3,804). Discordance between cystatin C and creatinine-based eGFR (eGFRdiff < -10 mL/min/1.73 m2) vs. eGFRdiff -10 to 10 mL/min/1.73 m2 was evaluated on Major adverse cardiovascular events (MACE) (HR 1.50). An eGFRdiff below -10 mL/min/1.73 m2 was associated with an increased risk of major adverse cardiovascular events (HR 1.50) and heart failure hospitalization in patients with atrial fibrillation.
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