Non-valvular Atrial Fibrillation in CKD: Role of Vitamin K Antagonists and Direct Oral Anticoagulants. A Narrative Review.

Atrial fibrillation (AF) is the most common arrhythmia in chronic kidney disease (CKD), with a close bidirectional relationship between the two entities. The presence of CKD in AF increases the risk of thromboembolic events, mortality and bleeding. Vitamin K antagonists (VKA) have been the mainstay of treatment for the prevention of thromboembolic events in AF until recently, with confirmed benefits in AF patients with stage 3 CKD. However, the risk-benefit profile of VKA in patients with AF and stages 4-5 CKD is controversial due to the lack of evidence from randomized controlled trials. Treatment with VKA in CKD patients has been associated with conditions such as poorer anticoagulation quality, increased risk of bleeding, faster progression of vascular/valvular calcification and higher risk of calciphylaxis. Direct oral anticoagulants (DOACs) have shown equal or greater efficacy in stroke/systemic embolism prevention, and a better safety profile than VKA in post-hoc analysis of the pivotal randomized controlled trials in patients with non-valvular AF and stage 3 CKD, yet evidence of its risk-benefit profile in more advanced stages of CKD is scarce. Observational studies associate DOACs with a good safety/effectiveness profile compared to VKA in non-dialysis CKD patients. Further, DOACs have been associated with a lower risk of acute kidney injury and CKD development/progression than VKA. This narrative review summarizes the evidence of the efficacy and safety of warfarin and DOACs in patients with AF at different CKD stages, as well as their effects on renal function, vascular/valvular calcification and bone health.

Anticoagulación oral en la enfermedad renal crónica con fibrilación auricular / Oral anticoagulation in chronic kidney disease with atrial fibrillation

La enfermedad renal crónica (ERC) y la fibrilación auricular (FA) frecuentemente coexisten, amplificando el riesgo de eventos cardiovasculares y de mortalidad. En pacientes con ERC estadio 3 y FA no valvular los anticoagulantes orales de acción directa (ACOD) han demostrado, comparados con antagonistas de la vitamina K (AVK), igual o superior eficacia en la prevención de ictus y embolismo sistémico, y mayor seguridad. No existen ensayos aleatorizados de la eficacia y la seguridad de ACOD y AVK en la ERC avanzada. Por otra parte, estudios observacionales sugieren que los ACOD, comparados con warfarina, se asocian a menor riesgo de daño renal agudo y de generación/progresión de la ERC. En este trabajo se revisan los aspectos epidemiológicos y fisiopatológicos de la asociación ERC y FA, las evidencias de la eficacia y seguridad de la warfarina y de los ACOD en las diversas fases de la ERC con FA, así como la comparación entre warfarina y ACOD en la eficacia y seguridad anticoagulante, y en sus efectos renales

Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist, amplifying the risk of cardiovascular events and mortality. In patients with CKD stage 3 and non-valvular AF, direct oral anticoagulants (DOACs) have shown, compared to vitamin K antagonists (VKA), equal or greater efficacy in the prevention of stroke and systemic embolism, and greater safety. There are no randomized trials of the efficacy and safety of DOACs and VKA in advanced CKD. On the other hand, observational studies suggest that DOACs, compared to warfarin, are associated with a lower risk of acute kidney damage and generation/progression of CKD. This paper reviews the epidemiological and pathophysiological aspects of the CKD and AF association, the evidence of the efficacy and safety of warfarin and ACODs in various stages of CKD with AF as well as the comparison between warfarin and ACODs in efficacy and anticoagulant safety, and in its renal effects

Oral anticoagulation in chronic kidney disease with atrial fibrillation.

Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist, amplifying the risk of cardiovascular events and mortality. In patients with CKD stage 3 and non-valvular AF, direct oral anticoagulants (DOACs) have shown, compared to vitamin K antagonists (VKA), equal or greater efficacy in the prevention of stroke and systemic embolism, and greater safety. There are no randomizedtrials of the efficacy and safety of DOACs and VKA in advanced CKD. On the other hand, observational studies suggest that DOACs, compared to warfarin, are associated with a lower risk of acute kidney damage and generation/progression of CKD. This paper reviews the epidemiological and pathophysiological aspects of the CKD and AF association, the evidence of the efficacy and safety of warfarin and ACODs in various stages of CKD with AF as well as the comparison between warfarin and ACODs in efficacy and anticoagulant safety, and in its renal effects.

Oral anticoagulation in chronic kidney disease with atrial fibrillation. / Anticoagulación oral en la enfermedad renal crónica con fibrilación auricular.

Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist, amplifying the risk of cardiovascular events and mortality. In patients with CKD stage3 and non-valvular AF, direct oral anticoagulants (DOACs) have shown, compared to vitaminK antagonists (VKA), equal or greater efficacy in the prevention of stroke and systemic embolism, and greater safety. There are no randomized trials of the efficacy and safety of DOACs and VKA in advanced CKD. On the other hand, observational studies suggest that DOACs, compared to warfarin, are associated with a lower risk of acute kidney damage and generation/progression of CKD. This paper reviews the epidemiological and pathophysiological aspects of the CKD and AF association, the evidence of the efficacy and safety of warfarin and ACODs in various stages of CKD with AF as well as the comparison between warfarin and ACODs in efficacy and anticoagulant safety, and in its renal effects.

[Utility of cardiac event recorders in diagnosing arrhythmic etiology of palpitations in patients without structural heart disease]. / Utilidad de un grabador de acontecimientos en el diagnóstico de la etiología arrítmica de las palpitaciones en pacientes sin cardiopatía estructural.

OBJECTIVE: To determine the diagnostic yield of transtelephonic event monitors for identifying the reason for palpitations in patients with no structural heart disease. PATIENTS AND METHOD: For 20 months we enrolled all patients reporting palpitations in whom heart disease had been ruled out by medical history, physical examination, ECG and transthoracic echocardiography. All patients underwent 24 h Holter monitoring, which did not provide diagnostic information. Later, a Cardiotest 4DM transtelephonic event monitor was provided to each patient for a mean of 15 3 days. We used SPSS V 10 for statistical analysis. RESULTS: Two hundred twenty-seven consecutive patients were enrolled. Mean age was 45 3 years (range 12-85); 167 were females (74%). Two hundred twelve of the 227 patients (93.3%) experienced palpitations while wearing the device, and 210 (92.5%) used the monitor correctly, recording the cardiac rhythm during palpitations. Fifteen patients (6.6%) had no palpitations during the days of study. In 125 (55%) the Cardiotest 4DM correctly recorded and transmitted arrhythmia that justified the patients' reference to palpitations. In 35 (15.4%) significant arrhythmia was detected: paroxysmal supraventricular tachycardia in 21, atrial fibrillation in 9, atrial flutter in 5, runs of ventricular extrasystoles in 4 and right outflow tract ventricular tachycardia in 1. Sinus rhythm was recorded during palpitations in 85 patients (37%), and arrhythmia as the cause could be ruled out. CONCLUSIONS: Cardiotest 4DM identifies arrhythmia in a very high proportion of patients with palpitations and no structural heart disease.

Utilidad de un grabador de acontecimientos en el diagnóstico de la etiología arrítmica de las palpitaciones en pacientes sin cardiopatía estructural / Utility of Cardiac Event Recorders in Diagnosing Arrhythmic Etiology of Palpitations in Patients without Structural Heart Disease

Introducción y objetivos. El objetivo del presente trabajo es determinar cuál es el rendimiento de la utilización del grabador de acontecimientos en el diagnóstico de la etiología de las palpitaciones como síntoma en pacientes sin cardiopatía estructural. Pacientes y método. Durante 20 meses se han incluido en el estudio a todos los pacientes que consultaban por palpitaciones y en los que se descartaba mediante historia clínica, exploración, ECG y ecocardiografía la existencia de cardiopatía estructural. A todos se les realizó un Holter de 24 h que no resultó diagnóstico. Posteriormente se les proporció un registrador de acontecimientos Cardiotest 4DM® durante una media de 15 ñ 3 días. Utilizamos el paquete estadístico SPSS V.10.Resultados. Se incluyeron en el estudio 227 pacientes consecutivos. La edad media fue de 45 ñ 3 años (rango, 12-85 años) y 167 eran mujeres (74 por ciento). Un total de 212 de los 227 pacientes incluidos (93,3 por ciento) tuvieron palpitaciones durante los 15 días que dispusieron del monitor, y 210 (92,5 por ciento) utilizaron correctamente el monitor, grabando el ritmo cardíaco coexistente con dichas palpitaciones. Quince pacientes (6,6 por ciento) no tuvieron palpitaciones durante los días de estudio. En 125 (55 por ciento) el Cardiotest 4DM® grabó y transmitió por vía transtelefónica correctamente arritmias que justificaban las palpitaciones referidas por los pacientes. En 35 pacientes (15,4 por ciento) se detectaron arritmias significativas: 21 taquicardias paroxísticas supraventriculares, 9 fibrilaciones auriculares, 5 aleteos auriculares, 4 tripletes de extrasístoles ventriculares y una taquicardia ventricular de tracto de salida de ventrículo derecho. En 85 pacientes (37 por ciento), durante las palpitaciones no se detectó arritmia alguna que las justificara, excluyendo así las arritmias como etiología de la misma. Conclusiones. El Cardiotest 4DM® permite identificar arritmias en una proporción muy elevada de pacientes con palpitaciones y sin cardiopatía estructural conocida (AU)