Net Clinical Benefit of Antithrombotic Therapy in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Nationwide Observational Cohort Studys

Anders Nissen Bonde; Gregory Y H Lip; Anne-Lise Kamper; Peter Riis Hansen; Morten Lamberts; Kristine Hommel; Morten Lock Hansen; Gunnar Hilmar Gislason; Christian Torp-Pedersen; Jonas Bjerring Olesen

doi:10.1016/j.jacc.2014.09.051

Net Clinical Benefit of Antithrombotic Therapy in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Nationwide Observational Cohort Studys

Anders Nissen Bonde, Gregory Y H Lip, Anne-Lise Kamper, Peter Riis Hansen, Morten Lamberts, Kristine Hommel, Morten Lock Hansen, Gunnar Hilmar Gislason, Christian Torp-Pedersen, Jonas Bjerring Olesen

Department of Clinical Medicine

184 Citations (Scopus)

Abstract

Background The balance between stroke reduction and increased bleeding associated with antithrombotic therapy among patients with atrial fibrillation (AF) and chronic kidney disease (CKD) is controversial. Objectives This study assessed the risk associated with CKD in individual CHA₂DS₂-VASc (Congestive heart failure; Hypertension; Age ≥75 years; Diabetes mellitus; previous Stroke, transient ischemic attack, or thromboembolism; Vascular disease; Age 65 to 74 years; Sex category) strata and the net clinical benefit of warfarin in patients with AF and CKD in a nationwide cohort. Methods By individual-level linkage of nationwide Danish registries, we identified all patients discharged with nonvalvular AF from 1997 to 2011. The stroke risk associated with non-end-stage CKD and end-stage CKD (e.g., patients on renal replacement therapy [RRT]) was estimated using Cox regression analyses. The net clinical benefit of warfarin was assessed using 4 endpoints: a composite endpoint of death/hospitalization from stroke/bleeding; a composite endpoint of fatal stroke/fatal bleeding; cardiovascular death; and all-cause death. RESULTS From nonvalvular AF patients (n = 154,259), we identified 11,128 patients (7.2%) with non-end-stage CKD and 1,728 (1.1%) receiving RRT. In all CHA₂DS₂-VASc risk groups, RRT was independently associated with a higher risk of stroke/thromboembolism, from a 5.5-fold higher risk in patients with CHA₂DS₂-VASc score = 0 to a 1.6-fold higher risk in patients with CHA2DS2-VASc score ≥2. In patients receiving RRT with CHA₂DS₂-VASc score≥2, warfarin was associated with lower risk of all-cause death (hazard ratio [HR]: 0.85, 95% confidence interval [CI]: 0.72 to 0.99). In non-end-stage CKD patients with CHA₂DS₂-VASc score ≥2, warfarin was associated with a lower risk of a composite outcome of fatal stroke/fatal bleeding (HR: 0.71, 95% CI: 0.57 to 0.88), a lower risk of cardiovascular death (HR: 0.80, 95% CI: 0.74 to 0.88), and a lower risk of all-cause death (HR: 0.64, 95% CI: 0.60 to 0.69). Conclusions CKD is associated with a higher risk of stroke/thromboembolism across stroke risk strata in AF patients. High-risk CKD patients (CHA₂DS₂-VASc ≥2) with AF benefit from warfarin treatment for stroke prevention.

Original language	English
Journal	Journal of the American College of Cardiology
Volume	64
Issue number	23
Pages (from-to)	2471-2482
Number of pages	12
ISSN	0735-1097
DOIs	https://doi.org/10.1016/j.jacc.2014.09.051
Publication status	Published - 2014

Keywords

Aged
Anticoagulants
Aspirin
Atrial Fibrillation
Cohort Studies
Denmark
Female
Follow-Up Studies
Hemorrhage
Hospitalization
Humans
Male
Proportional Hazards Models
Registries
Renal Insufficiency, Chronic
Renal Replacement Therapy
Risk Assessment
Stroke
Thromboembolism
Warfarin

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1016/j.jacc.2014.09.051

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Bonde, A. N., Lip, G. Y. H., Kamper, A-L., Hansen, P. R., Lamberts, M., Hommel, K., Hansen, M. L., Gislason, G. H., Torp-Pedersen, C., & Olesen, J. B. (2014). Net Clinical Benefit of Antithrombotic Therapy in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Nationwide Observational Cohort Studys. Journal of the American College of Cardiology, 64(23), 2471-2482. https://doi.org/10.1016/j.jacc.2014.09.051

Net Clinical Benefit of Antithrombotic Therapy in Patients With Atrial Fibrillation and Chronic Kidney Disease : A Nationwide Observational Cohort Studys. / Bonde, Anders Nissen; Lip, Gregory Y H; Kamper, Anne-Lise et al.

In: Journal of the American College of Cardiology, Vol. 64, No. 23, 2014, p. 2471-2482.

Research output: Contribution to journal › Journal article › Research › peer-review

Bonde, AN, Lip, GYH, Kamper, A-L, Hansen, PR, Lamberts, M, Hommel, K, Hansen, ML, Gislason, GH, Torp-Pedersen, C & Olesen, JB 2014, 'Net Clinical Benefit of Antithrombotic Therapy in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Nationwide Observational Cohort Studys', Journal of the American College of Cardiology, vol. 64, no. 23, pp. 2471-2482. https://doi.org/10.1016/j.jacc.2014.09.051

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title = "Net Clinical Benefit of Antithrombotic Therapy in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Nationwide Observational Cohort Studys",

abstract = "Background The balance between stroke reduction and increased bleeding associated with antithrombotic therapy among patients with atrial fibrillation (AF) and chronic kidney disease (CKD) is controversial. Objectives This study assessed the risk associated with CKD in individual CHA2DS2-VASc (Congestive heart failure; Hypertension; Age ≥75 years; Diabetes mellitus; previous Stroke, transient ischemic attack, or thromboembolism; Vascular disease; Age 65 to 74 years; Sex category) strata and the net clinical benefit of warfarin in patients with AF and CKD in a nationwide cohort. Methods By individual-level linkage of nationwide Danish registries, we identified all patients discharged with nonvalvular AF from 1997 to 2011. The stroke risk associated with non-end-stage CKD and end-stage CKD (e.g., patients on renal replacement therapy [RRT]) was estimated using Cox regression analyses. The net clinical benefit of warfarin was assessed using 4 endpoints: a composite endpoint of death/hospitalization from stroke/bleeding; a composite endpoint of fatal stroke/fatal bleeding; cardiovascular death; and all-cause death. RESULTS From nonvalvular AF patients (n = 154,259), we identified 11,128 patients (7.2%) with non-end-stage CKD and 1,728 (1.1%) receiving RRT. In all CHA2DS2-VASc risk groups, RRT was independently associated with a higher risk of stroke/thromboembolism, from a 5.5-fold higher risk in patients with CHA2DS2-VASc score = 0 to a 1.6-fold higher risk in patients with CHA2DS2-VASc score ≥2. In patients receiving RRT with CHA2DS2-VASc score≥2, warfarin was associated with lower risk of all-cause death (hazard ratio [HR]: 0.85, 95% confidence interval [CI]: 0.72 to 0.99). In non-end-stage CKD patients with CHA2DS2-VASc score ≥2, warfarin was associated with a lower risk of a composite outcome of fatal stroke/fatal bleeding (HR: 0.71, 95% CI: 0.57 to 0.88), a lower risk of cardiovascular death (HR: 0.80, 95% CI: 0.74 to 0.88), and a lower risk of all-cause death (HR: 0.64, 95% CI: 0.60 to 0.69). Conclusions CKD is associated with a higher risk of stroke/thromboembolism across stroke risk strata in AF patients. High-risk CKD patients (CHA2DS2-VASc ≥2) with AF benefit from warfarin treatment for stroke prevention.",

keywords = "Aged, Anticoagulants, Aspirin, Atrial Fibrillation, Cohort Studies, Denmark, Female, Follow-Up Studies, Hemorrhage, Hospitalization, Humans, Male, Proportional Hazards Models, Registries, Renal Insufficiency, Chronic, Renal Replacement Therapy, Risk Assessment, Stroke, Thromboembolism, Warfarin",

author = "Bonde, {Anders Nissen} and Lip, {Gregory Y H} and Anne-Lise Kamper and Hansen, {Peter Riis} and Morten Lamberts and Kristine Hommel and Hansen, {Morten Lock} and Gislason, {Gunnar Hilmar} and Christian Torp-Pedersen and Olesen, {Jonas Bjerring}",

year = "2014",

doi = "10.1016/j.jacc.2014.09.051",

language = "English",

volume = "64",

pages = "2471--2482",

journal = "Journal of the American College of Cardiology",

issn = "0735-1097",

publisher = "Elsevier",

number = "23",

}

TY - JOUR

T1 - Net Clinical Benefit of Antithrombotic Therapy in Patients With Atrial Fibrillation and Chronic Kidney Disease

T2 - A Nationwide Observational Cohort Studys

AU - Bonde, Anders Nissen

AU - Lip, Gregory Y H

AU - Kamper, Anne-Lise

AU - Hansen, Peter Riis

AU - Lamberts, Morten

AU - Hommel, Kristine

AU - Hansen, Morten Lock

AU - Gislason, Gunnar Hilmar

AU - Torp-Pedersen, Christian

AU - Olesen, Jonas Bjerring

PY - 2014

Y1 - 2014

N2 - Background The balance between stroke reduction and increased bleeding associated with antithrombotic therapy among patients with atrial fibrillation (AF) and chronic kidney disease (CKD) is controversial. Objectives This study assessed the risk associated with CKD in individual CHA2DS2-VASc (Congestive heart failure; Hypertension; Age ≥75 years; Diabetes mellitus; previous Stroke, transient ischemic attack, or thromboembolism; Vascular disease; Age 65 to 74 years; Sex category) strata and the net clinical benefit of warfarin in patients with AF and CKD in a nationwide cohort. Methods By individual-level linkage of nationwide Danish registries, we identified all patients discharged with nonvalvular AF from 1997 to 2011. The stroke risk associated with non-end-stage CKD and end-stage CKD (e.g., patients on renal replacement therapy [RRT]) was estimated using Cox regression analyses. The net clinical benefit of warfarin was assessed using 4 endpoints: a composite endpoint of death/hospitalization from stroke/bleeding; a composite endpoint of fatal stroke/fatal bleeding; cardiovascular death; and all-cause death. RESULTS From nonvalvular AF patients (n = 154,259), we identified 11,128 patients (7.2%) with non-end-stage CKD and 1,728 (1.1%) receiving RRT. In all CHA2DS2-VASc risk groups, RRT was independently associated with a higher risk of stroke/thromboembolism, from a 5.5-fold higher risk in patients with CHA2DS2-VASc score = 0 to a 1.6-fold higher risk in patients with CHA2DS2-VASc score ≥2. In patients receiving RRT with CHA2DS2-VASc score≥2, warfarin was associated with lower risk of all-cause death (hazard ratio [HR]: 0.85, 95% confidence interval [CI]: 0.72 to 0.99). In non-end-stage CKD patients with CHA2DS2-VASc score ≥2, warfarin was associated with a lower risk of a composite outcome of fatal stroke/fatal bleeding (HR: 0.71, 95% CI: 0.57 to 0.88), a lower risk of cardiovascular death (HR: 0.80, 95% CI: 0.74 to 0.88), and a lower risk of all-cause death (HR: 0.64, 95% CI: 0.60 to 0.69). Conclusions CKD is associated with a higher risk of stroke/thromboembolism across stroke risk strata in AF patients. High-risk CKD patients (CHA2DS2-VASc ≥2) with AF benefit from warfarin treatment for stroke prevention.

AB - Background The balance between stroke reduction and increased bleeding associated with antithrombotic therapy among patients with atrial fibrillation (AF) and chronic kidney disease (CKD) is controversial. Objectives This study assessed the risk associated with CKD in individual CHA2DS2-VASc (Congestive heart failure; Hypertension; Age ≥75 years; Diabetes mellitus; previous Stroke, transient ischemic attack, or thromboembolism; Vascular disease; Age 65 to 74 years; Sex category) strata and the net clinical benefit of warfarin in patients with AF and CKD in a nationwide cohort. Methods By individual-level linkage of nationwide Danish registries, we identified all patients discharged with nonvalvular AF from 1997 to 2011. The stroke risk associated with non-end-stage CKD and end-stage CKD (e.g., patients on renal replacement therapy [RRT]) was estimated using Cox regression analyses. The net clinical benefit of warfarin was assessed using 4 endpoints: a composite endpoint of death/hospitalization from stroke/bleeding; a composite endpoint of fatal stroke/fatal bleeding; cardiovascular death; and all-cause death. RESULTS From nonvalvular AF patients (n = 154,259), we identified 11,128 patients (7.2%) with non-end-stage CKD and 1,728 (1.1%) receiving RRT. In all CHA2DS2-VASc risk groups, RRT was independently associated with a higher risk of stroke/thromboembolism, from a 5.5-fold higher risk in patients with CHA2DS2-VASc score = 0 to a 1.6-fold higher risk in patients with CHA2DS2-VASc score ≥2. In patients receiving RRT with CHA2DS2-VASc score≥2, warfarin was associated with lower risk of all-cause death (hazard ratio [HR]: 0.85, 95% confidence interval [CI]: 0.72 to 0.99). In non-end-stage CKD patients with CHA2DS2-VASc score ≥2, warfarin was associated with a lower risk of a composite outcome of fatal stroke/fatal bleeding (HR: 0.71, 95% CI: 0.57 to 0.88), a lower risk of cardiovascular death (HR: 0.80, 95% CI: 0.74 to 0.88), and a lower risk of all-cause death (HR: 0.64, 95% CI: 0.60 to 0.69). Conclusions CKD is associated with a higher risk of stroke/thromboembolism across stroke risk strata in AF patients. High-risk CKD patients (CHA2DS2-VASc ≥2) with AF benefit from warfarin treatment for stroke prevention.

KW - Aged

KW - Anticoagulants

KW - Aspirin

KW - Atrial Fibrillation

KW - Cohort Studies

KW - Denmark

KW - Female

KW - Follow-Up Studies

KW - Hemorrhage

KW - Hospitalization

KW - Humans

KW - Male

KW - Proportional Hazards Models

KW - Registries

KW - Renal Insufficiency, Chronic

KW - Renal Replacement Therapy

KW - Risk Assessment

KW - Stroke

KW - Thromboembolism

KW - Warfarin

U2 - 10.1016/j.jacc.2014.09.051

DO - 10.1016/j.jacc.2014.09.051

M3 - Journal article

C2 - 25500231

SN - 0735-1097

VL - 64

SP - 2471

EP - 2482

JO - Journal of the American College of Cardiology

JF - Journal of the American College of Cardiology

IS - 23

ER -

Net Clinical Benefit of Antithrombotic Therapy in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Nationwide Observational Cohort Studys

Abstract

Keywords

UN SDGs

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