P3845Use of oral anticoagulation and association to outcomes in atrial fibrillation patients who develop chronic kidney disease: a nationwide cohort study

Abstract

Background: Patients with chronic kidney disease (CKD) have generally been excluded from randomized controlled clinical trials of oral anticoagulation (OAC) in atrial fibrillation (AF). All non-vitamin K antagonist oral anticoagulants (NOAC) have some renal excretion. Purpose: To determine the efficacy and safety of vitamin K antagonists (VKA) and NOACs in AF patients who develop CKD. Methods: We identified all AF patients who were diagnosed with first-time CKD after the first NOAC became available in Denmark. Median estimated glomerular filtration rate has previously been found to be 25 mL/min/1.73m2 in patients with CKD diagnosis. Patients were categorized according to OAC strategy at time of first CKD diagnosis. Outcomes were stroke/thromboembolism (TE), major bleeding, and all-cause mortality. We used Cox regression to estimate hazard ratios (HR), 95% confidence intervals (CI) and standardized absolute risks. Results: We included 8761 AF patients who developed CKD during the study period. Median age was 79 years (interquartile range 72-85). After CKD diagnosis, 4455 (50%) patients were discharged with no OAC, 3478 (40%) on VKA, 320 (4%) on dabigatran, 250 (3%) on rivaroxaban and 258 (3%) on apixaban. 63 (8%) of NOAC users did not receive reduced dose. Use of any OAC was associated with lower risk of stroke/TE (HR 0.83, CI 0.69-1.00, p=0.049), and all-cause mortality (HR 0.79, CI 0.73-0.86), but higher risk of major bleeding (HR 1.22, CI 1.07-1.39). Use of NOAC, compared with VKA, was associated with similar risk of stroke/TE (HR 0.90, CI 0.61-1.33), but lower risk of major bleeding (HR 0.75, CI 0.57-0.98). Individual NOACs, compared with VKA, had similar associations with stroke/TE and all-cause mortality, but rivaroxaban was associated with less major bleeding (HR 0.57, CI 0.34-0.95). Conclusions: Among AF patients who develop CKD, use of OAC is associated with reduced risk of stroke/TE and all-cause mortality, but increased risk of major bleeding. NOACs appear to be safe and effective alternatives to VKA for stroke prevention in this population. (Figure Presented).