Clinical outcomes and treatment patterns among Medicare patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease


Autoři: Lauren E. Wilson aff001;  Xuemei Luo aff002;  Xiaoyan Li aff003;  Jack Mardekian aff002;  Alessandra B. Garcia Reeves aff003;  Asheley Skinner aff001
Působiště autorů: Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, United States of America aff001;  Pfizer, Inc., New York City, NY, United States of America aff002;  Bristol Myers-Squibb Company, New York City, NY, United States of America aff003;  University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America aff004
Vyšlo v časopise: PLoS ONE 14(11)
Kategorie: Research Article
doi: 10.1371/journal.pone.0225052

Souhrn

Background

Patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease (CKD) have increased risk of adverse outcomes. This study evaluated treatment with oral anticoagulants and outcomes in elderly NVAF patients with CKD.

Methods

Retrospective observational cohort study of US Medicare fee-for-service patients aged ≥66 years with comorbid CKD (advanced: Stage 4 and higher; less advanced: Stages 1–3) and a new NVAF diagnoses from 2011–2013. All-cause mortality, stroke, major bleeding, and myocardial infarction rates were estimated for 1 year post-NVAF diagnosis. Associations between CKD stage and outcomes were evaluated with multivariate-adjusted Cox regression. We assessed oral anticoagulant (OAC) receipt within 90 days post-NVAF diagnosis and associations between OAC receipt and outcomes.

Results

There were 198,380 eligible patients (79,681 with advanced CKD). After adjustment for age, gender, and comorbidities, advanced CKD was associated with increased mortality (Stage 5 HR 1.47; 95% CI 1.42–1.52), MI (HR 1.48; 95% CI 1.33–1.64), stroke (HR 1.23; 95% CI 1.11–1.37) and major bleed (HR 1.44; 95% CI 1.36–1.53) risks. Among Medicare Part D enrollees who survived ≥90 days post-NVAF diagnosis, 65–71% received no OACs in the first 90 days. Those receiving warfarin (HR 0.73; 95% CI 0.71–0.75) or DOACs (HR 0.52; 95% CI 0.49–0.56) within the first 90 days had reduced mortality in the period 90 days to 1 year following NVAF diagnosis compared to those without.

Conclusion

Elderly NVAF patients with advanced CKD (Stage 4 or higher) had higher mortality risks and serious clinical outcomes than those with less advanced CKD (Stage 1–3). OAC use was low across all CKD stages, but was associated with a lower mortality risk than no OAC use in the first year post-NVAF diagnosis.

Klíčová slova:

Death rates – Hemorrhagic stroke – Chronic kidney disease – Ischemic stroke – Medicare – Myocardial infarction – Geriatric nephrology


Zdroje

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Článek vyšel v časopise

PLOS One


2019 Číslo 11