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Non-valvular Atrial Fibrillation in CKD: Role of Vitamin K Antagonists and Direct Oral Anticoagulants. A Narrative Review.

ABSTRACT: Atrial fibrillation (AF) is the most common arrhythmia in chronic kidney disease (CKD), with a close bidirectional relationship between the two entities. The presence of CKD in AF increases the risk of thromboembolic events, mortality and bleeding. Vitamin K antagonists (VKA) have been the mainstay of treatment for the prevention of thromboembolic events in AF until recently, with confirmed benefits in AF patients with stage 3 CKD. However, the risk-benefit profile of VKA in patients with AF and stages 4-5 CKD is controversial due to the lack of evidence from randomized controlled trials. Treatment with VKA in CKD patients has been associated with conditions such as poorer anticoagulation quality, increased risk of bleeding, faster progression of vascular/valvular calcification and higher risk of calciphylaxis. Direct oral anticoagulants (DOACs) have shown equal or greater efficacy in stroke/systemic embolism prevention, and a better safety profile than VKA in post-hoc analysis of the pivotal randomized controlled trials in patients with non-valvular AF and stage 3 CKD, yet evidence of its risk-benefit profile in more advanced stages of CKD is scarce. Observational studies associate DOACs with a good safety/effectiveness profile compared to VKA in non-dialysis CKD patients. Further, DOACs have been associated with a lower risk of acute kidney injury and CKD development/progression than VKA. This narrative review summarizes the evidence of the efficacy and safety of warfarin and DOACs in patients with AF at different CKD stages, as well as their effects on renal function, vascular/valvular calcification and bone health.

SUBMITTER: Cases A

PROVIDER: S-EPMC8484537 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundDirect oral anticoagulants (DOACs) and warfarin are usually used for people with atrial fibrillation (AF). However, for the AF patients at risk of falling, the effectiveness and safety outcomes of DOACs compared with warfarin remain unclear. Therefore, we performed a meta-analysis regarding the effectiveness and safety of DOACs vs. warfarin in AF patients at risk of falling.MethodsA search of the PubMed and Embase databases until November 2021 was performed. We included studies if they satisfied the following criteria: (1) study type: randomized clinical trials or observational cohort studies. (2) Comparisons: effectiveness and/or safety of DOACs (dabigatran, rivaroxaban, apixaban, or edoxaban) compared with warfarin. (3) Study data: the sample size, the number of events in the VKAs or DOACs groups, adjusted risk ratios (RRs), and 95% confidence intervals (CIs). (4) Study outcomes: stroke or systemic embolism (SSE), ischemic stroke, myocardial infarction (MI), all-cause death, and cardiovascular death; major bleeding, major or clinically relevant non-major (CRNM) bleeding, intracranial bleeding, gastrointestinal bleeding, and any bleeding. (5) Study population: patients at risk of falling. According to the Morse Fall Scale, the risk of falling relates to the history of falling, secondary diagnosis, ambulatory aids, intravenous therapy, type of gait, and mental status. In this meta-analysis, if the patient's MFS score is ≥25 points, he will be thought of as having the risk of falling. The adjusted risk ratios (RRs) and 95% confidence intervals (CIs) were pooled by a random-effects model with an inverse variance method.ResultsThree cohort studies were included in our study. For the effectiveness outcomes, the use of DOACs was only associated with a significantly reduced risk of hemorrhagic stroke (RR = 0.28, 95%CI:0.10-0.75) compared with warfarin, but there were no significant differences in stroke or systemic embolism (SSE) (RR = 0.87, 95%CI:0.70-1.08), cardiovascular death (RR = 0.97, 95%CI:0.73-1.29) and all-cause death (RR = 0.90, 95%CI:0.72-1.11). For the safety outcomes, the use of DOACs was significantly associated with reduced risks of major or clinically relevant non-major bleeding (RR = 0.77, 95%CI:0.61-0.98) and intracranial bleeding (RR = 0.26, 95%CI:0.11-0.66) but not major bleeding (RR = 0.78, 95%CI:0.58-1.06).ConclusionsCompared with warfarin, the use of DOACs in AF patients at risk of falling is significantly associated with reduced risks of hemorrhagic stroke, major or clinically relevant non-major bleeding, and intracranial bleeding.

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Non-valvular Atrial Fibrillation in CKD: Role of Vitamin K Antagonists and Direct Oral Anticoagulants. A Narrative Review.

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