Variability in Nonvitamin K Oral Anticoagulant Dose Eligibility and Adjustment According to Renal Formulae and Clinical Outcomes in Patients With Atrial Fibrillation With and Without Chronic Kidney Disease: Insights From ORBIT‐AF II

Background Nonvitamin K oral anticoagulants require dose adjustment based on kidney function.The most common estimate of kidney function employed in clinical practice is estimated glomerular filtration rate (eGFR); however, product monographs recommend the use of the Cockcroft-Gault estimated creati...

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Vydané v:Journal of the American Heart Association Ročník 12; číslo 6; s. e026605
Hlavní autori: Yao, Ren Jie Robert, Holmes, DaJuanicia N., Andrade, Jason G., Levin, Adeera, Piccini, Jonathan P., Fordyce, Christopher B.
Médium: Journal Article
Jazyk:English
Vydavateľské údaje: England John Wiley and Sons Inc 21.03.2023
Wiley
Predmet:
Administration, Oral
Anticoagulants - therapeutic use
atrial fibrillation
Atrial Fibrillation - complications
Atrial Fibrillation - diagnosis
Atrial Fibrillation - drug therapy
Dabigatran
Humans
nonvitamin K oral anticoagulant
ORBIT‐AF II
Original Research
renal dose adjustment
Renal Insufficiency, Chronic - complications
Renal Insufficiency, Chronic - diagnosis
Renal Insufficiency, Chronic - epidemiology
Rivaroxaban
Stroke - diagnosis
Stroke - epidemiology
Stroke - etiology
ORBIT‐AF II
atrial fibrillation
nonvitamin K oral anticoagulant
renal dose adjustment
ISSN:2047-9980, 2047-9980
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Shrnutí:Background Nonvitamin K oral anticoagulants require dose adjustment based on kidney function.The most common estimate of kidney function employed in clinical practice is estimated glomerular filtration rate (eGFR); however, product monographs recommend the use of the Cockcroft-Gault estimated creatinine clearance (eCrCl) for dose adjustment. Methods and Results The authors included patients enrolled in the ORBIT-AF II (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation AF II) trial. Dosing was considered inappropriate when use of eGFR resulted in a lower (undertreatment) or higher (overtreatment) dose than that recommended by the eCrCl. The primary outcome of major adverse cardiovascular and neurological events was a composite of cardiovascular death, stroke or systemic embolism, new-onset heart failure, and myocardial infarction. Among 8727 in the overall cohort, agreement between eCrCl and eGFR was observed in 93.5% to 93.8% of patients. Among 2184 patients with chronic kidney disease (CKD), the agreement between eCrCl and eGFR was 79.9% to 80.7%. Dosing misclassification was more frequent in the CKD population (41.9% of rivaroxaban users, 5.7% of dabigatran users, and 4.6% apixaban users). At 1 year, undertreated patients in the CKD group had significantly greater major adverse cardiovascular and neurological events (adjusted hazard ratio, 2.93 [95% CI, 1.08-7.92]) compared with the group with appropriate nonvitamin K oral anticoagulants dosing ( =0.03). Conclusions The prevalence of misclassification of nonvitamin K oral anticoagulants dosing was high when using eGFR, particularly among patients with CKD. Among patients with CKD, potential undertreatment due to inappropriate and off-label renal formulae may result in worse clinical outcomes. These findings highlight the importance of using eCrCl, and not eGFR, for dose adjustment in all patients with AF receiving nonvitamin K oral anticoagulants.
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Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/JAHA.122.026605
For Sources of Funding and Disclosures, see page 13.
ISSN:2047-9980
2047-9980
DOI:10.1161/JAHA.122.026605