Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD USA.
Optimal Aging Institute, New York University Grossman School of Medicine and Langone Health New York NY USA.
J Am Heart Assoc. 2024 Aug 20;13(16):e034641. doi: 10.1161/JAHA.123.034641. Epub 2024 Aug 9.
Patients with atrial fibrillation and severe chronic kidney disease have higher risks of bleeding, thromboembolism, and mortality. However, optimal anticoagulant choice in these high-risk patients remains unclear.
Using deidentified electronic health records from the Optum Labs Data Warehouse, adults with atrial fibrillation and severe chronic kidney disease (estimated glomerular filtration rate <30 mL/min per 1.73 m) initiating warfarin, apixaban, or rivaroxaban between 2011 and 2021 were included. Using inverse probability of treatment weighting, adjusted risks of major bleeding, stroke/systemic embolism, and death were compared among agents. A total of 6794 patients were included (mean age, 78.5 years; mean estimated glomerular filtration rate, 24.7 mL/min per 1.73 m; 51% women). Apixaban versus warfarin was associated with a lower risk of major bleeding (incidence rate, 1.5 versus 2.9 per 100 person-years; subdistribution hazard ratio [sub-HR], 0.53 [95% CI, 0.39-0.70]), and similar risks for stroke/systemic embolism (incidence rate, 1.9 versus 2.4 per 100 person-years; sub-HR, 0.80 [95% CI, 0.59-1.09]) and death (incidence rate, 4.6 versus 4.5 per 100 person-years; HR, 1.03 [95% CI, 0.82-1.29]). Rivaroxaban versus warfarin was associated with a higher risk of major bleeding (incidence rate, 4.9 versus 2.9 per 100 person-years; sub-HR, 1.65 [95% CI, 1.10-2.48]), with no difference in risks for stroke/systemic embolism and death. Apixaban versus rivaroxaban was associated with a lower risk of major bleeding (sub-HR, 0.53 [95% CI, 0.36-0.78]).
These real-world findings are consistent with potential safety advantages of apixaban over warfarin and rivaroxaban for patients with atrial fibrillation and severe chronic kidney disease. Further randomized trials comparing individual oral anticoagulants are warranted.
患有心房颤动和严重慢性肾病的患者出血、血栓栓塞和死亡的风险较高。然而，在这些高危患者中，最佳抗凝药物选择仍不明确。
利用 Optum Labs 数据仓库中的匿名电子健康记录，纳入 2011 年至 2021 年期间开始使用华法林、阿哌沙班或利伐沙班的患有心房颤动和严重慢性肾病（估计肾小球滤过率<30ml/min/1.73m）的成年人。使用逆概率治疗加权法，比较了药物之间大出血、卒中和全身性栓塞以及死亡的调整风险。共纳入 6794 例患者（平均年龄 78.5 岁；平均估计肾小球滤过率 24.7ml/min/1.73m；51%为女性）。与华法林相比，阿哌沙班出血风险较低（发生率，1.5 比 2.9/100 人年；亚分布风险比 [sub-HR]，0.53[95%CI，0.39-0.70]），卒中和全身性栓塞风险相似（发生率，1.9 比 2.4/100 人年；sub-HR，0.80[95%CI，0.59-1.09]）和死亡率（发生率，4.6 比 4.5/100 人年；HR，1.03[95%CI，0.82-1.29]）。与华法林相比，利伐沙班大出血风险较高（发生率，4.9 比 2.9/100 人年；sub-HR，1.65[95%CI，1.10-2.48]），卒中和全身性栓塞及死亡率无差异。与利伐沙班相比，阿哌沙班大出血风险较低（sub-HR，0.53[95%CI，0.36-0.78]）。
这些真实世界的数据结果与阿哌沙班相对于华法林和利伐沙班在患有心房颤动和严重慢性肾病患者中具有潜在安全性优势的结论一致。需要进一步的随机试验来比较各种口服抗凝药物。
