Affiliation:
1. Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD USA
2. Optimal Aging Institute, New York University Grossman School of Medicine and Langone Health New York NY USA
3. Department of Population Health New York University Grossman School of Medicine and Langone Health New York NY USA
4. Department of Nephrology Geisinger Health System Danville PA USA
5. Division of Nephrology, Department of Internal Medicine Tufts Medical Center Boston MA USA
6. Department of Medicine New York University Grossman School of Medicine and Langone Health New York NY USA
Abstract
Background
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.
Methods and Results
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
2
) 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
2
; 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]).
Conclusions
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.
Publisher
Ovid Technologies (Wolters Kluwer Health)