Cochrane for Clinicians

Putting Evidence into Practice

Direct Oral Anticoagulants vs. Warfarin to Prevent Stroke and Embolic Events in Patients with Atrial Fibrillation and CKD

 

Am Fam Physician. 2019 Apr 1;99(7):422-423.

Author disclosure: No relevant financial affiliations.

Clinical Question

Are direct oral anticoagulants safe and effective for preventing stroke and embolism in patients with atrial fibrillation and chronic kidney disease (CKD)?

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SUMMARY TABLE: DIRECT ORAL ANTICOAGULANTS VS. WARFARIN TO PREVENT STROKE AND EMBOLISM IN PATIENTS WITH ATRIAL FIBRILLATION AND CKD

OutcomeRelative risk (95% CI)Assumed risk: warfarinCorresponding risk (95% CI): direct oral anticoagulantsNumber of participants (number of studies)

All strokes and systemic embolic events

0.81 (0.65 to 1.00)

29 per 1,000

23 per 1,000 (19 to 29)

12,545 (5)

Major bleeding

0.79 (0.59 to 1.04)

55 per 1,000

43 per 1,000 (32 to 57)

12,521 (5)

Gastrointestinal bleeding

1.40 (0.97 to 2.01)

17 per 1,000

24 per 1,000 (17 to 35)

5,678 (2)

Intracranial hemorrhage

0.43 (0.27 to 0.69)

14 per 1,000

6 per 1,000 (4 to 9)

12,521 (5)

All-cause mortality

0.91 (0.78 to 1.05)

78 per 1,000

71 per 1,000 (61 to 82)

9,595 (4)


Note: Follow-up was 1.8 to 2.8 years.

CKD = chronic kidney disease.

SUMMARY TABLE: DIRECT ORAL ANTICOAGULANTS VS. WARFARIN TO PREVENT STROKE AND EMBOLISM IN PATIENTS WITH ATRIAL FIBRILLATION AND CKD

OutcomeRelative risk (95% CI)Assumed risk: warfarinCorresponding risk (95% CI): direct oral anticoagulantsNumber of participants (number of studies)

All strokes and systemic embolic events

0.81 (0.65 to 1.00)

29 per 1,000

23 per 1,000 (19 to 29)

12,545 (5)

Major bleeding

0.79 (0.59 to 1.04)

55 per 1,000

43 per 1,000 (32 to 57)

12,521 (5)

Gastrointestinal bleeding

1.40 (0.97 to 2.01)

17 per 1,000

24 per 1,000 (17 to 35)

5,678 (2)

Intracranial hemorrhage

0.43 (0.27 to 0.69)

14 per 1,000

6 per 1,000 (4 to 9)

12,521 (5)

All-cause mortality

0.91 (0.78 to 1.05)

78 per 1,000

71 per 1,000 (61 to 82)

9,595 (4)


Note: Follow-up was 1.8 to 2.8 years.

CKD = chronic kidney disease.

Evidence-Based Answer

Direct oral anticoagulants are as likely as warfarin to prevent all strokes and systemic embolic events in patients with atrial fibrillation and CKD stage 3. They do not increase the risk of major bleeding events. The evidence remains insufficient to make recommendations for the use of direct oral anticoagulants in the management of patients with atrial fibrillation and CKD stage 4 or 5.1 (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)

Practice Pointers

Atrial fibrillation and CKD are independent risk factors for stroke and embolic events.2 Current evidence suggests an improved health-related quality of life with the use of direct oral anticoagulants vs. traditional treatment with vitamin K antagonists (e.g., warfarin) for patients with an increased risk of stroke.3 The authors of this Cochrane review sought to determine the safety and effectiveness of stroke and embolism prevention with direct oral anticoagulants vs. warfarin in the management of chronic, nonvalvular atrial fibrillation in patients with CKD stage 3 and 4.1

This Cochrane review included five trials involving 12,545 patients. The follow-up time ranged from 1.8 to 2.8 years. Identified studies compared direct oral anticoagulants and warfarin to prevent stroke (including ischemic, hemorrhagic, or unspecified) and embolism in patients with nonvalvular atrial fibrillation and moderate CKD (i.e., stage 3 and 4), defined as a creatinine clearance between 15 and 60 mL per minute per 1.73 m2.

Patients who used direct oral anticoagulants seemed

Author disclosure: No relevant financial affiliations.

References

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1. Kimachi M, Furukawa TA, Kimachi K, Goto Y, Fukuma S, Fukuhara S. Direct oral anticoagulants versus warfarin for preventing stroke and systemic embolic events among atrial fibrillation patients with chronic kidney disease. Cochrane Database Syst Rev. 2017;(11):CD011373....

2. Olesen JB, Lip GY, Kamper AL, et al. Stroke and bleeding in atrial fibrillation with chronic kidney disease [published correction appears in N Engl J Med. 2012;367(23):2262]. N Engl J Med. 2012;367(7):625–635.

3. Suárez Fernández C, Castilla-Guerra L, Cantero Hinojosa J, et al. Satisfaction with oral anticoagulants in patients with atrial fibrillation. Patient Prefer Adherence. 2018;12:267–274.

4. Shahid F, Shantsila E, Lip GY. Treatment of atrial fibrillation in patients with chronic kidney disease: is stroke prevention worth the risk? Chest. 2016;149(4):891–892.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.

A collection of Cochrane for Clinicians published in AFP is available at https://www.aafp.org/afp/cochrane.

 

 

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