Shankar Kumar1, Simon de Lusignan2, Andrew McGovern2,3, Ana Correa2,4, Mariya Hriskova2,4, Piers Gatenby2,5, Simon Jones2,6, David Goldsmith7,8, A John Camm9. 1. Centre for Medical Imaging, University College London, London, UK. 2. Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK. 3. Exeter Medical School, University of Exeter, Exeter, UK. 4. Royal College of General Practitioners Research and Surveillance Centre, London, UK. 5. Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK. 6. Department of Population Health, Division of Healthcare Delivery Science, NYU School of Medicine, New York, USA. 7. Molecular and Clinical Sciences Research Institute, St George's University of London, UK. 8. Renal and Transplantation Department, Guys and St Thomas' Hospitals NHS Foundation Trust, London, UK. 9. Molecular and Clinical Sciences Research Institute, St George's University of London, UK jcamm@sgul.ac.uk.
Abstract
OBJECTIVE: To assess the association between anticoagulation, ischaemic stroke, gastrointestinal and cerebral haemorrhage, and all cause mortality in older people with atrial fibrillation and chronic kidney disease. DESIGN: Propensity matched, population based, retrospective cohort analysis from January 2006 through December 2016. SETTING: The Royal College of General Practitioners Research and Surveillance Centre database population of almost 2.73 million patients from 110 general practices across England and Wales. PARTICIPANTS: Patients aged 65 years and over with a new diagnosis of atrial fibrillation and estimated glomerular filtration rate (eGFR) of <50 mL/min/1.73m2, calculated using the chronic kidney disease epidemiology collaboration creatinine equation. Patients with a previous diagnosis of atrial fibrillation or receiving anticoagulation in the preceding 120 days were excluded, as were patients requiring dialysis and recipients of renal transplants. INTERVENTION: Receipt of an anticoagulant prescription within 60 days of atrial fibrillation diagnosis. MAIN OUTCOME MEASURES: Ischaemic stroke, cerebral or gastrointestinal haemorrhage, and all cause mortality. RESULTS: 6977 patients with chronic kidney disease and newly diagnosed atrial fibrillation were identified, of whom 2434 were on anticoagulants within 60 days of diagnosis and 4543 were not. 2434 pairs were matched using propensity scores by exposure to anticoagulant or none and followed for a median of 506 days. The crude rates for ischaemic stroke and haemorrhage were 4.6 and 1.2 after taking anticoagulants and 1.5 and 0.4 in patients who were not taking anticoagulant per 100 person years, respectively. The hazard ratios for ischaemic stroke, haemorrhage, and all cause mortality for those on anticoagulants were 2.60 (95% confidence interval 2.00 to 3.38), 2.42 (1.44 to 4.05), and 0.82 (0.74 to 0.91) compared with those who received no anticoagulation. CONCLUSION: Giving anticoagulants to older people with concomitant atrial fibrillation and chronic kidney disease was associated with an increased rate of ischaemic stroke and haemorrhage but a paradoxical lowered rate of all cause mortality. Careful consideration should be given before starting anticoagulants in older people with chronic kidney disease who develop atrial fibrillation. There remains an urgent need for adequately powered randomised trials in this population to explore these findings and to provide clarity on correct clinical management. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
OBJECTIVE: To assess the association between anticoagulation, ischaemic stroke, gastrointestinal and cerebral haemorrhage, and all cause mortality in older people with atrial fibrillation and chronic kidney disease. DESIGN: Propensity matched, population based, retrospective cohort analysis from January 2006 through December 2016. SETTING: The Royal College of General Practitioners Research and Surveillance Centre database population of almost 2.73 million patients from 110 general practices across England and Wales. PARTICIPANTS: Patients aged 65 years and over with a new diagnosis of atrial fibrillation and estimated glomerular filtration rate (eGFR) of <50 mL/min/1.73m2, calculated using the chronic kidney disease epidemiology collaboration creatinine equation. Patients with a previous diagnosis of atrial fibrillation or receiving anticoagulation in the preceding 120 days were excluded, as were patients requiring dialysis and recipients of renal transplants. INTERVENTION: Receipt of an anticoagulant prescription within 60 days of atrial fibrillation diagnosis. MAIN OUTCOME MEASURES: Ischaemic stroke, cerebral or gastrointestinal haemorrhage, and all cause mortality. RESULTS: 6977 patients with chronic kidney disease and newly diagnosed atrial fibrillation were identified, of whom 2434 were on anticoagulants within 60 days of diagnosis and 4543 were not. 2434 pairs were matched using propensity scores by exposure to anticoagulant or none and followed for a median of 506 days. The crude rates for ischaemic stroke and haemorrhage were 4.6 and 1.2 after taking anticoagulants and 1.5 and 0.4 in patients who were not taking anticoagulant per 100 person years, respectively. The hazard ratios for ischaemic stroke, haemorrhage, and all cause mortality for those on anticoagulants were 2.60 (95% confidence interval 2.00 to 3.38), 2.42 (1.44 to 4.05), and 0.82 (0.74 to 0.91) compared with those who received no anticoagulation. CONCLUSION: Giving anticoagulants to older people with concomitant atrial fibrillation and chronic kidney disease was associated with an increased rate of ischaemic stroke and haemorrhage but a paradoxical lowered rate of all cause mortality. Careful consideration should be given before starting anticoagulants in older people with chronic kidney disease who develop atrial fibrillation. There remains an urgent need for adequately powered randomised trials in this population to explore these findings and to provide clarity on correct clinical management. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Authors: Tim A Holt; Andrew Rh Dalton; Susan Kirkpatrick; Jenny Hislop; Tom Marshall; Matthew Fay; Nadeem Qureshi; Daniel S Lasserson; Karen Kearley; Jill Mollison; Ly-Mee Yu; David Fitzmaurice; Fd Richard Hobbs Journal: Br J Gen Pract Date: 2018-11-05 Impact factor: 5.386
Authors: Igor Kremenevski; Oliver Sander; Michael Sticherling; Martin Raithel; FirstName MiddleName LastName Journal: Dtsch Arztebl Int Date: 2022-02-11 Impact factor: 8.251
Authors: Amber O Molnar; William Petrcich; Matthew A Weir; Amit X Garg; Michael Walsh; Manish M Sood Journal: Nephrol Dial Transplant Date: 2020-05-01 Impact factor: 5.992
Authors: M Harries; A E Macbeth; S Holmes; W S Chiu; W R Gallardo; M Nijher; S de Lusignan; C Tziotzios; A G Messenger Journal: Br J Dermatol Date: 2021-10-21 Impact factor: 11.113
Authors: Angela Koverech; Valeriano Soldati; Vittoria Polidori; Leda Marina Pomes; Luana Lionetto; Matilde Capi; Andrea Negro; Maurizio Simmaco; Paolo Martelletti Journal: Int J Environ Res Public Health Date: 2018-08-02 Impact factor: 3.390