Nishimura Marin, Hsu Jonathan C
Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, California.
Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, California.
Am J Cardiol. 2018 Jan 1;121(1):131-140. doi: 10.1016/j.amjcard.2017.09.030. Epub 2017 Oct 12.
Over the past decade, there have been tremendous advancements in anticoagulation therapies for stroke prevention in patients with atrial fibrillation (AF). Although the non-vitamin K antagonist oral anticoagulants (NOACs) demonstrated favorable clinical outcomes compared with warfarin overall, the decision to anticoagulate and the choice of appropriate agent in patients with AF and concomitant chronic kidney disease (CKD) or end-stage renal disease (ESRD) are a particularly complex issue. CKD and ESRD increase both the risk of stroke and bleeding, and since all of the NOACs undergo various levels of renal clearance, renal dysfunction inevitably affects the pharmacokinetics of the drug in each patient. Furthermore, the randomized controlled clinical trials of each NOAC versus warfarin often did not include patients with advanced CKD or ESRD. In this focused review, we describe the available evidence supporting the use of NOACs for prevention of stroke in patients with AF with concomitant advanced CKD or ESRD. Although questions of safety and appropriate use of these new agents in CKD and ESRD remain, NOACs offer a significant step forward in the anticoagulation management of at-risk patients with AF.
在过去十年中，心房颤动（AF）患者预防中风的抗凝治疗取得了巨大进展。尽管与华法林相比，非维生素K拮抗剂口服抗凝剂（NOACs）总体上显示出良好的临床效果，但在AF合并慢性肾脏病（CKD）或终末期肾病（ESRD）患者中，决定是否进行抗凝以及选择合适的药物是一个特别复杂的问题。CKD和ESRD会增加中风和出血的风险，并且由于所有NOACs都有不同程度的肾脏清除，肾功能不全不可避免地会影响每位患者体内药物的药代动力学。此外，每种NOAC与华法林的随机对照临床试验通常不包括晚期CKD或ESRD患者。在这篇重点综述中，我们描述了支持在AF合并晚期CKD或ESRD患者中使用NOACs预防中风的现有证据。尽管这些新药在CKD和ESRD中的安全性和合理使用问题仍然存在，但NOACs在高危AF患者的抗凝管理方面向前迈出了重要一步。
