Citations

Atrial fibrillation (AF) is an important comorbidity in patients with end-stage renal disease (ESRD) undergoing dialysis that portends increased health care utilization, morbidity, and mortality in this already high-risk population. Patients with ESRD have a particularly high stroke risk, which is further compounded by AF. However, the role of anticoagulation for stroke prophylaxis in ESRD and AF is debated. The ESRD population presents a unique challenge because of the combination of elevated stroke and bleeding risks. Warfarin has been traditionally used in this population, but it is associated with significant risks of minor and major bleeding, particularly intracranial, thus leading many clinicians to forgo anticoagulation altogether. When anticoagulation is prescribed, rates of adherence and persistence are poor, leaving many patients untreated. The direct oral anticoagulants (DOACs) may offer an alternative to warfarin in ESRD patients, but these agents have not been extensively studied in this population and uncertainties regarding comparative effectiveness (versus warfarin, each other, and no treatment) remain. In this review, we discuss the current evidence on the risk and benefits of anticoagulants in this challenging population and comparisons between warfarin and DOACs, and review future directions including options for non-pharmacologic stroke prevention.

Background Atrial fibrillation is the most common arrhythmia worldwide. Data regarding 30‐day readmission rates after discharge for atrial fibrillation remain poorly reported. Methods and Results The Nationwide Readmission Database (2010–2014) was queried using the International Classification of Diseases, Ninth Revision ( ICD‐9 ) codes to identify study population. Incidence, etiologies of 30‐day readmission and predictors of 30‐day readmissions, and cost of care were analyzed. Among 1 723 378 patients who survived to discharge, 249 343 (14.4%) patients were readmitted within 30 days. Compared with the readmitted group, the nonreadmitted group had higher utilization of electrical cardioversion and catheter ablation. Atrial fibrillation was the most common cause of readmission (24.1%). Median time to 30‐day readmission was 13 days. Advancing age, female sex, and longer stay during index hospitalization predicted higher 30‐day readmissions, whereas private insurance, electrical cardioversion, catheter ablation, higher income, and elective admissions correlated with lower 30‐day readmission. Comorbidities such as heart failure, neurological disorder, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, chronic liver failure, coagulopathy, anemia, peripheral vascular disease, and electrolyte disturbance, correlated with increased 30‐day readmissions and cost burden. Trend analysis showed a progressive decline in 30‐day readmission rates from 14.7% in 2010 to 14.3% in 2014 ( P trend, <0.001). Conclusions Approximately 1 in 7 patients were readmitted within 30 days of discharge, with symptomatic atrial fibrillation being the most common cause. We identified a predictive model for increased risk of readmissions and treatment expense. Electrical cardioversion during index admission was associated with a significant reduction in 30‐day readmissions and service charges. The 30‐day readmissions correlated with a substantial rise in the cost of care.

AbstractThere is increasing recognition of silent and clinically apparent thromboembolic events after left‐sided ventricular tachycardia (VT) ablation. However, unlike atrial fibrillation ablation procedures where postablation oral anticoagulation (OAC) is universal, there is significant practice variation in OAC use after VT ablation. Herein, we review the data on post‐VT ablation thromboembolism and evidence on the use of OAC, we suggest that OAC merits consideration in most cases after a balanced assessment of risks and benefits in individual patients, and we discuss future directions.

Background: Stroke prevention using warfarin is challenging in AF patients with CKD, due to high bleeding risk and difficulties in the INR control. NOACs provide alternative options, but all have greater degrees of renal clearance. This study aimed to compare the outcomes of apixaban, dabigatran, rivaroxaban, and warfarin across the range of kidney function in patients with AF. Methods: Using a US administrative database including private insurance or Medicare Advantage patients with linked claims and laboratory data, we identified 34,569 new users of oral anticoagulants with AF and eGFR ≥15 between 10/1/2010-11/29/2017. Stabilized IPTW balanced four treatment groups on 66 baseline characteristics. The primary outcomes included stroke, major bleeding, and mortality. Weighted Cox proportional hazards models compared treatments in the overall population and in each eGFR subgroup, with mortality as a competing risk for stroke and major bleeding. Results: The proportion of patients using warfarin increased as the kidney function declined - 26.5%, 30.4%, 34.6%, 40.5%, and 55.0% of patients were prescribed warfarin in eGFR ≥90, 60-90, 45-60, 30-45, 15-30 groups, respectively. In comparison to warfarin, apixaban was associated with a lower risk of stroke, major bleeding, and mortality; dabigatran was associated with a similar risk of stroke, and a lower risk of major bleeding and mortality; rivaroxaban was associated with a lower risk of stroke, major bleeding, and mortality (Figure). When comparing one NOAC to another NOAC, apixaban and dabigatran were associated with a lower risk of major bleeding than rivaroxaban (HR 0.61 [0.51-0.73], p<0.001 for apixaban versus rivaroxaban; HR 0.67 [0.50-0.90], p=0.007 for dabigatran versus rivaroxaban); dabigatran was associated with a higher risk of stroke than apixaban (HR 1.65 [1.11-2.46], p=0.01); there was no difference in mortality. There was no significant interaction between treatment and eGFR categories for any outcome, but the number of patients with low eGFR was small. Conclusions: In practice, relative to warfarin, NOACs are progressively less commonly used with increasing degree of renal dysfunction. However, each NOAC was consistently associated with at least equivalent effectiveness and safety compared with warfarin across the range of kidney function.