Cardiorenal Outcomes Among Patients With Atrial Fibrillation Treated With Oral Anticoagulants.
Academic Article
Overview
abstract
RATIONALE & OBJECTIVE: Direct oral anticoagulants (DOAC) have progressively replaced vitamin K antagonists (VKA) for stroke prevention in patients with non-valvular atrial fibrillation (AF). DOACs cause fewer bleeding complications but other advantages of DOACs, particularly related to kidney outcomes, remain inconclusive. We studied the risks of CKD progression and AKI following DOAC and VKA administration for non-valvular AF. STUDY DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Cohort study of non-valvular AF patients resident in Stockholm, Sweden, during 2011-2018. EXPOSURE: Initiation of DOACs or VKA treatment. OUTCOME(S): Primary outcomes were CKD progression (composite of >30% eGFR decline and kidney failure) and AKI (by diagnosis or KDIGO-defined transient creatinine elevations). Secondary outcomes were death, major bleeding, and the composite of stroke and systemic embolism. ANALYTICAL APPROACH: Propensity-score weighted Cox regression was used to balance 50 baseline confounders. Sensitivity analyses included falsification endpoints, subgroups, and estimation of per-protocol effects. RESULTS: 32,699 patients were included (56% initiated DOAC) and followed for median 3.8 years. Their median age was 75 years, 45% were women and 27% had eGFR<60 ml/min/1.73 m2. The adjusted hazard ratio for DOAC vs. VKA was 0.87 (95% CI 0.78-0.98) for the risk of CKD progression and 0.88 (95% CI 0.80-0.97) for AKI. Hazard ratios were 0.77 (95% CI 0.67-0.89) for major bleeding, 0.93 (95% CI 0.78-1.11) for the composite of stroke/systemic embolism, and 1.04 (95% CI 0.95-1.14) for death. Results were similar across subgroups of age, sex and baseline eGFR, when restricting to patients at high risk for thromboembolic events, and when censoring follow up at treatment discontinuation or switches in type of anticoagulation. LIMITATIONS: Missing information on time in therapeutic range and treatment dosages. CONCLUSIONS: Among patients with non-valvular AF treated in routine clinical practice, compared with VKA, DOAC use was associated with a lower risk of CKD progression, AKI, and major bleeding, but a similar risk of the composite of stroke/systemic embolism and death.
