Stroke prevention in atrial fibrillation patients with chronic kidney disease.
Author(s): Hart RG(1), Eikelboom JW, Brimble KS, McMurtry MS, Ingram AJ.
Affiliation(s): Author information:
(1)Department of Medicine (Neurology), McMaster University, Hamilton, Ontario,
Canada. robert.hart@phri.ca
Publication date & source: 2013, Can J Cardiol. , 29(7 Suppl):S71-8
Chronic kidney disease (CKD) is prevalent in elderly patients with atrial
fibrillation and is an independent risk factor for stroke. Warfarin
anticoagulation is efficacious for stroke prevention in atrial fibrillation
patients with moderate CKD (stage III, estimated glomerular filtration rate 30-59
mL/min), but recent observational studies have challenged its value for patients
with end-stage renal disease requiring dialysis. The novel oral anticoagulants
(i.e., dabigatran, apixaban, rivaroxaban) all undergo renal metabolism to varying
degrees, and hence dosing, efficacy, and safety require special consideration in
CKD patients. In randomized trials to date involving 11,169 patients with
moderate CKD, the novel oral anticoagulants performed well, with similar efficacy
and safety profiles as for non-CKD patients. For atrial fibrillation patients
with stage III CKD, the available data are strongest for dabigatran 150 mg twice
daily as superior to warfarin for stroke prevention and for apixaban as superior
to warfarin regarding reduced major hemorrhage. Renal function should be
monitored at least annually in patients receiving a novel oral anticoagulant, and
more often in elderly patients and those with underlying CKD or comorbidities who
are at special risk for dehydration and deterioration of renal function. Much
remains to be learned about the optimal use of the novel oral anticoagulants in
CKD patients; additional studies about optimal dosing of the novel oral
anticoagulants and frequency of monitoring renal function in CKD patients with
atrial fibrillation are needed. Anticoagulation options for hemodialysis patients
require testing in randomized trials.
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