Elsevier

American Heart Journal

Volume 166, Issue 2, August 2013, Pages 230-239
American Heart Journal

Curriculum in Cardiology
Management of atrial fibrillation in chronic kidney disease: Double trouble

https://doi.org/10.1016/j.ahj.2013.05.010Get rights and content

Chronic kidney disease (CKD) has a very well-established link with cardiovascular disease. Below stage 3 CKD (glomerular filtration rate <60 mL/min), there is a progressive increase in both total mortality and cardiovascular-specific mortality as kidney function declines; indeed, it is more likely for a patient with CKD stage 3 to die of cardiovascular disease than to progress to CKD stage 4 and beyond. Arrhythmia is particularly common in patients with CKD. Depending on the study and measurement used, the prevalence of patients with CKD with chronic atrial fibrillation (AF) is quoted at 7% to 18%, rising to 12% to 25% for those older than 70 years. These rates are up to 2 to 3 times higher than in the general population. Of all patients with AF, 10% to 15% will have CKD. However, not all standard rate and rhythm methods are suitable for this population and those that are tend to be less effective. Meanwhile, anticoagulation has long been a thorny subject, with much conflicting evidence around the balance between bleeding and stroke risk. To help clarify this, we first highlight the challenges of performing evidence-based medicine in the patient with renal disease, and then review recent and emerging research to suggest an approach to the management of patients with renal disease who have AF. We also review the potential role of the different new oral anticoagulant drugs in CKD.

Section snippets

Barriers to treatment of CVD in patients with renal disease

Despite the fact that patients with CKD have large amounts of all types of CVD, they often do not receive the same access to appropriate treatment as patients with normal renal function.6 For example, it has been demonstrated that patients with CKD who have acute myocardial infarction are less likely to undergo coronary angiography or thrombolysis or receive optimal medical therapy, even when attempting to control for comorbidity.7 The challenges in treating CVD in patients with renal disease

Control of arrhythmia

The agents normally recommended for pharmacologic cardioversion in patients with CKD are shown in Table I. Of note, flecainide, commonly used in the general population, is best avoided. There are few cardioversion outcome data specifically for patients with renal disease. Recent work has shown that in 346 patients with CKD with post–myocardial infarction AF, significantly fewer (70% vs 84%) were in sinus rhythm at the time of hospital discharge postcardioversion than those with normal renal

Prevention of complications—anticoagulation

Because patients with renal disease are less likely to be cardioverted out of AF, it would seem logical to instead focus on the mitigation of potential complications. Yet again, this may be more challenging than it initially appears, although new evidence is appearing that finally may help give us more direction in the management of these patients. The major complication of AF is thromboembolism as a result of disorganized contraction of the atria. Ischemic stroke is probably the most

Vascular calcification—another argument against warfarin?

A frequently cited reason against use of warfarin in patients with CKD is that of vascular calcification. Renal failure creates a hyperphosphatemic environment that stimulates vascular smooth muscle cells in the arterial media to develop osteoblastic characteristic, initiating and regulating vascular calcification.38 Normally, Matrix G1a protein (which is vitamin K activated) inhibits this process. Therefore, vitamin K inhibition with warfarin could accelerate rates of vascular calcification.39

Aspirin as an antiplatelet intervention

In the general population, guidelines discourage use of aspirin for stroke prevention because it is well established to be significantly inferior to warfarin. A recent study comparing aspirin with apixaban in patients with stage 3 CKD deemed unsuitable for warfarin found that apixaban significantly reduced ischemic stroke/systemic embolism without increasing rates of bleeding.44 Because there is no evidence suggesting that aspirin is useful for stroke prevention in patients with CKD and may

New oral anticoagulants: do they show promise and which ones?

The last 5 years have seen the release of new oral anticoagulant therapies. Two direct thrombin inhibitors (ximelagatran and dabigatran) and 2 factor Xa inhibitors (apixaban and rivaroxaban) have been tested in large phase III randomized trials, although ximelagatran was later withdrawn because of hepatotoxicity.47, 48, 49 They have all shown noninferiority or superiority in the prevention of stroke in patients with AF when compared with adjusted-dose warfarin and are easier to take, with few

Conclusions

Management of patients with renal disease and AF, as with many of the other comorbidities they experience, is more complicated than that of their counterparts with normal kidney function. Many of the same treatments, particularly for rate and rhythm control, are still useful, although less effective. Likewise, catheter ablation is an option, although likewise may be less effective than in patients without renal disease.

The major complication of atrial fibrillation, ischemic stroke, is often

Disclosures

D.G. reports speaking and consulting honoraria for Merck, Sanofi, and Takeda. No extramural funding was used to support this work. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the manuscript, and its final contents.

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