Severity of renal impairment in patients with heart failure and atrial fibrillation: implications for non-vitamin K antagonist oral anticoagulant dose adjustment

Hawkins, N. M. et al. (2016) Severity of renal impairment in patients with heart failure and atrial fibrillation: implications for non-vitamin K antagonist oral anticoagulant dose adjustment. European Journal of Heart Failure, 18(9), pp. 1162-1171. (doi:10.1002/ejhf.614) (PMID:27594177)

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Abstract

Aims. The non-vitamin K antagonist oral anticoagulants (NOACs) have varying degrees of renal elimination which may be challenging in patients with heart failure (HF) and atrial fibrillation (AF). We examined the severity and variation in renal impairment, and the proportion of patients requiring NOAC cessation or dose reduction. Methods and results. Retrospective analysis of patients with HF and AF in the Candesartan in Heart failure Assessment of Reduction in Mortality and Morbidity program. Trends in renal impairment over 26 months were defined using Cockcroft-Gault (CG), simplified Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaborative (CKD-EPI) equations. Mean eGFR was worse at every time point in patients with AF compared to those without AF, the difference being approximately 11 ml/min (CG), 9 ml/min (CKD-EPI) and 7 ml/min (MDRD). As renal function declined, CG classified a greater proportion of patients as having moderate or severe CKD and agreement with MDRD/CKD-EPI declined. At least moderate renal impairment was present in one quarter of patients with AF at baseline, one third by study completion, and approaching one half at least once during follow-up. The projected need for NOAC dose reduction was accordingly high, though varied between individual NOACs due to different criteria for adjustment. Conclusions. Renal impairment in patients with HF and AF is common, fluctuates, progresses, and frequently mandates NOAC dose reduction, though the need for cessation is rare. Baseline renal function, the method of estimating GFR, and intensity of monitoring should be considered when commencing oral anticoagulation.

Item Type:Articles
Status:Published
Refereed:Yes
Glasgow Author(s) Enlighten ID:Jhund, Dr Pardeep and Petrie, Professor Mark and Pozzi, Dr Andrea and McMurray, Professor John
Authors: Hawkins, N. M., Jhund, P. S., Pozzi, A., O'Meara, E., Solomon, S. D., Granger, C. B., Yusuf, S., Pfeffer, M. A., Swedberg, K., Petrie, M. C., Virani, S., and McMurray, J. J.V.
College/School:College of Medical Veterinary and Life Sciences > Institute of Cardiovascular and Medical Sciences
Journal Name:European Journal of Heart Failure
Publisher:Wiley
ISSN:1388-9842
ISSN (Online):1879-0844
Published Online:05 September 2016
Copyright Holders:Copyright © 2016 The Authors
First Published:First published in European Journal of Heart Failure 18(9): 1162-1171
Publisher Policy:Reproduced in accordance with the copyright policy of the publisher

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