Author + information
- Received January 3, 2020
- Accepted January 7, 2020
- Published online March 16, 2020.
- Sean D. Pokorney, MD, MHSa,b,
- Eric Black-Maier, MDa,
- Anne S. Hellkamp, MSb,
- Daniel J. Friedman, MDc,
- Sreekanth Vemulapalli, MDb,
- Christopher B. Granger, MDb,
- Laine Thomas, PhDb,
- Eric D. Peterson, MD, MPHb and
- Jonathan P. Piccini Sr., MD, MHSa,b,∗ (, )@JonPicciniSr
- aDuke Center for Atrial Fibrillation, Duke University Medical Center, Durham, North Carolina
- bDuke Clinical Research Institute, Durham, North Carolina
- cDivision of Electrophysiology, Yale School of Medicine, New Haven, Connecticut
- ↵∗Address for correspondence:
Dr. Jonathan P. Piccini, Sr., Electrophysiology Section, Duke University Medical Center, P.O. Box 17969, Durham, North Carolina 27710.
Background Atrial fibrillation (AF) is common in patients with end-stage renal disease (ESRD). The impact of oral anticoagulation (OAC) in ESRD patients is uncertain.
Objectives The purpose of this study was to describe patterns of OAC use in ESRD patients with AF and their associations with cardiovascular outcomes.
Methods Using Medicare fee-for-service 5% claims data from 2007 to 2013, we analyzed treatment and outcomes in a cohort of patients with ESRD and AF. Prescription drug benefit information was used to determine the timing of OAC therapy. Cox proportional hazards modeling was used to compare outcomes including death, all-cause stroke, ischemic stroke, hemorrhagic stroke, and bleeding hospitalizations in ESRD patients treated with or without OAC.
Results The cohort included 8,410 patients with AF and ESRD. A total of 3,043 (36.2%) patients were treated with OAC at some time during the study period. Propensity scores used to match 1,519 patients with AF and ESRD on OAC with 3,018 ESRD patients without OAC. Treatment with OAC was not associated with hospitalization for stroke (hazard ratio [HR]: 1.00; 95% confidence interval [CI]: 0.23 to 1.35; p = 0.97) or death (HR: 1.02; 95% CI: 0.94 to 1.10; p = 0.62). OAC was associated with an increased risk of hospitalization for bleeding (HR: 1.26; 95% CI: 1.09 to 1.46; p = 0.0017) and intracranial hemorrhage (HR: 1.30; 95% CI: 1.07 to 1.59; p = 0.0094).
Conclusions OAC utilization was low in patients with AF and ESRD. We found no association between OAC use and reduced risk of stroke or death. OAC use was associated with increased risks of hospitalization for bleeding or intracranial hemorrhage. Alternative stroke prevention strategies are needed in patients with ESRD and AF.
This project was supported by grant number U19HS021092 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Additional funding was provided by the Duke Clinical Research Institute. Dr. Pokorney has received research grants from Boston Scientific, Janssen Pharmaceuticals, Bristol-Myers Squibb, Pfizer, and Gilead; has received consulting and research support from Bristol-Myers Squibb, Pfizer, Medtronic, Boston Scientific, and Janssen Pharmaceuticals; has received research support from the Food and Drug Administration; and has received Speakers Bureau support from Zoll. Dr. Friedman has received salary support from Boston Scientific and Abbott; has received consulting fees from Abbott and AtriCure; has received research support from Boston Scientific, Biosense Webster, and Abbott; and has received grants from Boston Scientific, Medtronic, Abbott, and Biotronik. Dr. Vemulapalli receives grants for clinical research from Abbott Vascular, Boston Scientific, National Institutes of Health, Patient Centered Outcomes Research Institute, Food and Drug Administration (NEST), American College of Cardiology, Society of Thoracic Surgeons; and serves as a consultant to Janssen, Boston Scientific, Heartflow, Baylabs (Caption Health), and the American College of Physicians. Dr. Granger has received funding support and/or honoraria from The Medicines Company, Pfizer, and AstraZeneca; and has been a consultant for Pfizer and AstraZeneca. Dr. Peterson has received grant support from the American College of Cardiology, the American Heart Association, and Janssen; and has served as a consultant for Bayer, Boehringer Ingelheim, Merck, Valeant, Sanofi, AstraZeneca, Janssen, Regeneron, and Genentech. Dr. Piccini has received grants for clinical research from Abbott, the American Heart Association, the Association for the Advancement of Medical Instrumentation, Bayer, Boston Scientific, and Philips; and has served as a consultant to Abbott, Allergan, ARCA Biopharma, Biotronik, Boston Scientific, LivaNova, Medtronic, Milestone, Myokardia, Sanofi, Philips, and Up-to-Date. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 3, 2020.
- Accepted January 7, 2020.
- 2020 American College of Cardiology Foundation
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