Don’t hesitate to prescribe direct oral anticoagulants in patient with atrial fibrillation associated with moderate chronic kidney disease

SOURCE

Kimachi M, Furukawa TA, Kimachi K et al (2017) Direct oral anticoagulants versus warfarin for preventing stroke and systemic embolic events among atrial fibrillation patients with chronic kidney disease. Cochrane Database Sys Rev 11:CD011373.

CONTEXT

Atrial fibrillation (AF) is a common pathology and its management has changed recently with the introduction of direct oral anticoagulants (DOAC). Chronic kidney disease (CKD) is an independent risk factor for AF and AF in subjects with CKD is associated with a high thromboembolic risk.

CLINICAL QUESTION

Are DOAC as effective and well tolerated as warfarin in the management of non-valvular AF in subjects with moderate to severe CKD (creatinine clearance between 15 and 60 ml/min)?

BOTTOM LINE

DOAC appear to prevent the occurrence of systemic strokes and embolism as well as warfarin (moderate quality evidence) without increasing the number of major bleedings (low quality evidence). DOAC reduces the incidence of intracranial hemorrhage compared to warfarin (moderate quality evidence). The use of DOAC does not impact all-cause mortality (moderate quality evidence).

CAVEAT

While subgroup analyses were initially planned, they could not be carried out due to lack of data (no stratification on haemorrhagic or thromboembolic risk, different assays of the molecules not taken into account, as well as their association or not with a platelet antiagregant). The authors did not distinguish the effect of anti-II versus anti-Xa. The follow-up period does not exceed 2.8 years, whereas these treatments are often prescribed for life. The number of subjects with creatinine clearance between 15 and 30 ml/min is too small to draw conclusions for this category of patients. This meta-analysis does not close the debate on a possible excess risk of digestive bleeding or myocardial infarction due to a lack of available data.

AUTHOR INFORMATION

S. BEROUD
Service d’Accueil des urgences, Hospices civils de Lyon, CHU Lyon-Sud,
Lyon, France
sebastien.beroud@chu-lyon.fr

P. JABRE
Samu de Paris, CHU Necker–Enfants-Malades, F-75730
Paris, France
patricia.jabre@aphp.fr

K. MAGEE
Dalhousie University – QEII Health Science Centre
Nova Scotia, Canada
kirk.magee@dal.ca