Incidence of thromboembolic stroke and of major bleeding in patients with atrial fibrillation and chronic kidney disease treated with and without warfarin

Hoang M Lai, Wilbert S Aronow, Phoenix Kalen, Sreedhar Adapa, Kaushal Patel, Arvind Goel, Ravi Vinnakota, Savneek Chugh, Renee Garrick, Hoang M Lai, Wilbert S Aronow, Phoenix Kalen, Sreedhar Adapa, Kaushal Patel, Arvind Goel, Ravi Vinnakota, Savneek Chugh, Renee Garrick

Abstract

The objective was to investigate the incidence of thromboembolic stroke in patients with chronic kidney disease (CKD) and atrial fibrillation (AF) treated with and without warfarin. We investigated the incidence of thromboembolic stroke and of major bleeding in 399 unselected patients with CKD and AF treated with warfarin to maintain an international normalized ratio (INR) between 2.0 and 3.0 (N = 232) and without warfarin (N = 167). Of the 399 patients, 93 (23%) were receiving hemodialysis, and 132 (33%) had an estimated glomerular filtration rate (GFR) of <15 mL/min/1.73 m(2) At the 31-month follow-up of patients treated with warfarin and 23-month follow-up of patients not treated with warfarin, thromboembolic stroke developed in 21 of 232 patients (9%) treated with warfarin and in 43 of 167 patients (26%) not treated with warfarin (P < 0.001). Major bleeding occurred in 32 of 232 patients (14%) treated with warfarin and in 15 of 167 patients (9%) not treated with warfarin (P not significant). Stepwise Cox regression analysis showed that significant independent predictors of thromboembolic stroke were use of warfarin (odds ratio, 0.28; P < 0.0001) and prior stroke or transient ischemic attack (odds ratio, 2.9; P < 0.05). In conclusion, this observational study showed that CKD patients with AF treated with warfarin to maintain an INR between 2.0 and 3.0 had a significant reduction in thromboembolic stroke and an insignificant increase in major bleeding.

Keywords: anticoagulants; atrial fibrillation; chronic kidney disease; major bleeding; thromboembolic stroke.

References

    1. Abe S, Yoshizawa M, Nakanishi N, et al. Electrocardiographic abnormalities in patients receiving hemodialysis. Am Heart J. 1996;131:1137–1144.
    1. Atar I, Konas D, Acikel S, et al. Frequency of atrial fibrillation and factors related to its development in dialysis patients. Int J Cardiol. 2006;106:47–51.
    1. Vazquez E, Sanchez-Perales C, Borrego F, et al. Influence of atrial fibrillation on the morbido-mortality of patients on hemodialysis. Am Heart J. 2000;140:886–890.
    1. Das M, Aronow WS, McClung JA, Belkin RN. Increased prevalence of coronary artery disease, silent myocardial ischemia, complex ventricular arrhythmias, atrial fibrillation, left ventricular hypertrophy, mitral annular calcium, and aortic valve calcium in patients with chronic renal insufficiency. Cardiol Rev. 2006;14:14–17.
    1. Fabbian F, Catalano C, Lambertini D, et al. Clinical characteristics associated to atrial fibrillation in chronic hemodialysis patients. Clin Nephrol. 2000;54:234–239.
    1. Genovesi S, Pogliani D, Faini A, et al. Prevalence of atrial fibrillation and associated factors in a population of long-term hemodialysis patients. Am J Kidney Dis. 2005;46:897–902.
    1. Vazquez E, Sanchez-Perales C, Lozano C, et al. Comparison of prognostic value of atrial fibrillation versus sinus rhythm in patients on long-term hemodiálysis. Am J Cardiol. 2003;92:868–871.
    1. Vazquez-Ruiz de Castroviejoa E, Sanchez-Perales C, Lozano-Cabezas C, et al. [Incidence of atrial fibrillation in hemodialysis patients. A prospective long-term follow-up study] Rev Esp Cardiol. 2006;59:779–784.
    1. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. N Engl J Med. 1990;323:1505–1511.
    1. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med. 1994;154:1449–1457.
    1. Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet. 1996;348:633–638.
    1. Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. EAFT (European Atrial Fibrillation Trial) Study Group. Lancet. 1993;342:1255–1262.
    1. Peterson P, Boysen G, Godtfredsen J, et al. Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation. Lancet. 1989;1:175–179.
    1. Preliminary report of the Stroke Prevention in Atrial Fibrillation Study. N Engl J Med. 1990;322:863–868.
    1. Stroke Prevention in Atrial Fibrillation Study Final results. Circulation. 1991;84:527–539.
    1. Connolly SJ, Laupacis A, Gent M, et al. Canadian Atrial Fibrillation Anticoagulation (CAFA) Study. J Am Coll Cardiol. 1991;18:345–355.
    1. Ezekowitz MD, Bridgers SL, James KE, et al. Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation. N Engl J Med. 1992;327:1406–1412.
    1. Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II Study. Lancet. 1994;343:687–691.
    1. Gullov AL, Koefoed BG, Petersen P, et al. Fixed minidose warfarin and aspirin alone and in combination vs adjusted-dose warfarin for stroke prevention in atrial fibrillation. Second Copenhagen Atrial Fibrillation, Aspirin, and Anticoagulation Study. Arch Intern Med. 1998;158:1513–1521.
    1. Aronow WS, Ahn C, Kronzon I, Gutstein H. Incidence of new thromboembolic stroke in persons ≥62 years old with chronic atrial fibrillation treated with warfarin versus aspirin. J Am Geriatr Soc. 1999;47:366–368.
    1. Aronow WS, Ahn C, Kronzon I, Gutstein H. Effect of warfarin versus aspirin on the incidence of new thromboembolic stroke in older persons with chronic atrial fibrillation and abnormal and normal left ventricular ejection fraction. Am J Cardiol. 2000;85:1033–1035.
    1. Aronow WS. Acute and chronic management of atrial fibrillation in patients with late-stage CKD. Am J Kidney Dis. 2009;53:701–710.
    1. Levey AS, Bosch JP, Lewis JB, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine. A new predictive equation. Ann Intern Med. 1999;130:461–470.
    1. National Kidney Foundation: Kidney Disease Outcome Quality Initiative (K/DOQI) clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(suppl 1):S1–S266.
    1. Ruioz-Nodar JM, Marin F, Hurtado JA, et al. Anticoagulant therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation. J Am Coll Cardiol. 2008;51:818–835.
    1. Abbott KC, Trespalacios FC, Taylor AJ, Agodoa LY. Atrial fibrillation in chronic dialysis patients in the United States: risk factors for hospitalization and mortality. BMC Nephrol. 2003;4:1.
    1. Korantzopoulos P, Kokkoris S, Liu T, Protopsaltis I, Li G, Goudevenos JA. Atrial fibrillation in end-stage renal disease. Pacing Clin Electrophysiol. 2007;30:1391–1397.
    1. Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: Executive summary. J Am Coll Cardiol. 2001;38:1231–1265.
    1. Vazquez E, Sanchez-Perales C, Garcia-Cortes J, et al. Ought dialysis patients with atrial fibrillation be treated with oral anticoagulants? Int J Cardiol. 2003;87:135–139.
    1. Wright JR, Kalra PA. Ought dialysis patients with atrial fibrillation be treated with oral anticoagulants? Int J Cardiol. 2003;87:139–141.
    1. Elliott MJ, Zimmerman D, Holden RM. Warfarin anticoagulation in hemodialysis patients: A systematic review of bleeding rates. Am J Kidney Dis. 2007;50:433–440.
    1. Quinn RR, Naimark DM, Oliver MJ, et al. Should hemodialysis patients undergo systemic anticoagulation? A cost-utility analysis. Am J Kidney Dis. 2007;50:421–432.
    1. Abbott KC, Neff RT, Bohen EM, Narayan R. Anticoagulation for chronic atrial fibrillation in hemodialysis patients: which fruit from the decision tree? Am J Kidney Dis. 2007;50:345–348.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir