Curriculum in CardiologyManagement of atrial fibrillation in chronic kidney disease: Double trouble
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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Cited by (31)
Changes in glomerular filtration rate and outcomes in patients with atrial fibrillation
2018, American Heart JournalImpact of moderate to severe renal impairment on long-term clinical outcomes in patients with atrial fibrillation
2017, Journal of CardiologyCitation Excerpt :Atrial fibrillation (AF) and chronic kidney disease (CKD) are prevalent clinical conditions and are associated with cardiovascular mortality and morbidity [1].
Atrial fibrillation in chronic kidney disease
2016, European Journal of Internal MedicineOutcomes after warfarin initiation in a cohort of hemodialysis patients with newly diagnosed atrial fibrillation
2015, American Journal of Kidney DiseasesCitation Excerpt :The benefits of oral anticoagulation for AF have been demonstrated in a number of randomized trials22; however, patients with ESRD were excluded from these studies. Therefore, whether the benefits of oral anticoagulation extend to patients undergoing hemodialysis is unclear23-25 because they have a substantially higher risk of stroke compared with the general population, but also a higher risk of bleeding.13,23-26 This clinical equipoise was reflected in a survey of Canadian nephrologists in which 72% were unsure about whether to initiate warfarin therapy in hemodialysis patients with AF27 and in the particularly low rate of warfarin use in hemodialysis patients with prevalent AF in which one-quarter were on warfarin therapy.28
Comparison of estimated glomerular filtration rate equations for dosing new oral anticoagulants in patients with atrial fibrillation
2015, Revista Espanola de CardiologiaImplications of Kidney Disease in the Cardiac Patient
2014, Interventional Cardiology ClinicsCitation Excerpt :There is, however, a general lack of strong data regarding the efficacy of warfarin and its ability to attenuate the rate of thromboembolic stroke in CKD patients, most data being retrospective and nonrandomized.69,72–75 Moreover, warfarin is associated with vascular calcification related to vitamin K antagonism, and there are reported risks of warfarin-related nephropathy.61 Despite this, current guidance continues to support the use of anticoagulation for thromboembolic risk reduction in the CKD cohort, which until recently has meant the administration and strict monitoring of warfarin.
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