Ischaemic stroke, haemorrhage, and mortality in older patients with chronic kidney disease newly started on anticoagulation for atrial fibrillation: a population based study from UK primary care.

Kumar, Shankar de Lusignan, Simon McGovern, Andrew Correa, Ana Hriskova, Mariya Gatenby, Piers Jones, Simon Goldsmith, David Camm, A John

REVIEW


03 July 2018

Comorbidity and the elderly are extremely important and topical issues. This article employs innovative and complex methods to look at the relationship between anticoagulants, ischaemic stroke and all-cause mortality. It has less clinical applicability because of the limited biological plausibility for a relationship between anticoagulants and ischaemic stroke, which calls for clinical trial in this area to improve outcomes for people with AF and CKD.


RELEVANCE 4
INNOVATIVENESS 4
APPLICABILITY 3
OVERALL 4

PAPER DETAILS


TITLE

Ischaemic stroke, haemorrhage, and mortality in older patients with chronic kidney disease newly started on anticoagulation for atrial fibrillation: a population based study from UK primary care.

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/1.73m, 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.



AUTHOR(S)

Kumar, Shankar de Lusignan, Simon McGovern, Andrew Correa, Ana Hriskova, Mariya Gatenby, Piers Jones, Simon Goldsmith, David Camm, A John

JOURNAL

BMJ (Clinical research ed.)

PLACE

England