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Management of Adults with Newly Diagnosed Atrial Fibrillation with and without CKD
Journal of the American Society of Nephrology ( IF 13.6 ) Pub Date : 2022-02-01 , DOI: 10.1681/asn.2021060744
Nisha Bansal 1 , Leila R Zelnick 2 , Kristi Reynolds 3, 4 , Teresa N Harrison 3 , Ming-Sum Lee 5 , Daniel E Singer 6, 7 , Sue Hee Sung 8 , Dongjie Fan 8 , Alan S Go 4, 8, 9, 10
Affiliation  

Background

Atrial fibrillation (AF) is highly prevalent in CKD and is associated with worse cardiovascular and kidney outcomes. Limited data exist on use of AF pharmacotherapies and AF-related procedures by CKD status. We examined a large "real-world" contemporary population with incident AF to study the association of CKD with management of AF.

Methods

We identified patients with newly diagnosed AF between 2010 and 2017 from two large, integrated health care delivery systems. eGFR (≥60, 45–59, 30–44, 15–29, <15 ml/min per 1.73 m2) was calculated from a minimum of two ambulatory serum creatinine measures separated by ≥90 days. AF medications and procedures were identified from electronic health records. We performed multivariable Fine–Gray subdistribution hazards regression to test the association of CKD severity with receipt of targeted AF therapies.

Results

Among 115,564 patients with incident AF, 34% had baseline CKD. In multivariable models, compared with those with eGFR >60 ml/min per 1.73 m2, patients with eGFR 30–44 (adjusted hazard ratio [aHR] 0.91; 95% CI, 0.99 to 0.93), 15–29 (aHR, 0.78; 95% CI, 0.75 to 0.82), and <15 ml/min per 1.73 m2 (aHR, 0.64; 95% CI, 0.58–0.70) had lower use of any AF therapy. Patients with eGFR 15–29 ml/min per 1.73 m2 had lower adjusted use of rate control agents (aHR, 0.61; 95% CI, 0.56 to 0.67), warfarin (aHR, 0.89; 95% CI, 0.84 to 0.94), and DOACs (aHR, 0.23; 95% CI, 0.19 to 0.27) compared with patients with eGFR >60 ml/min per 1.73 m2. These associations were even stronger for eGFR <15 ml/min per 1.73 m2. There was also a graded association between CKD severity and receipt of AF-related procedures (vs eGFR >60 ml/min per 1.73 m2): eGFR 30–44 ml/min per 1.73 (aHR, 0.78; 95% CI, 0.70 to 0.87), eGFR 15–29 ml/min per 1.73 m2 (aHR, 0.73; 95% CI, 0.61 to 0.88), and eGFR <15 ml/min per 1.73 m2 (aHR, 0.48; 95% CI, 0.31 to 0.74).

Conclusions

In adults with newly diagnosed AF, CKD severity was associated with lower receipt of rate control agents, anticoagulation, and AF procedures. Additional data on efficacy and safety of AF therapies in CKD populations are needed to inform management strategies.



中文翻译:

伴有和不伴有 CKD 的新诊断心房颤动成人的管理

背景

心房颤动 (AF) 在 CKD 中非常普遍,并且与较差的心血管和肾脏结果相关。根据 CKD 状态使用 AF 药物疗法和 AF 相关程序的数据有限。我们检查了大量“真实世界”的当代 AF 患者,以研究 CKD 与 AF 管理的关联。

方法

我们从两个大型综合医疗服务系统中确定了 2010 年至 2017 年间新诊断的 AF 患者。eGFR(≥60、45–59、30–44、15–29、<15 ml/min/1.73 m 2)是根据间隔≥90 天的最少两次动态血清肌酐测量值计算得出的。AF 药物和程序是从电子健康记录中确定的。我们进行了多变量 Fine-Gray 子分布风险回归,以测试 CKD 严重程度与接受靶向 AF 治疗的关联。

结果

在 115,564 名发生 AF 的患者中,34% 患有基线 CKD。在多变量模型中,与 eGFR >60 ml/min/1.73 m 2的患者相比,eGFR 30–44(调整后风险比 [aHR] 0.91;95% CI,0.99 至 0.93)、15–29(aHR,0.78)的患者; 95% CI, 0.75 to 0.82), and <15 ml/min per 1.73 m 2 (aHR, 0.64; 95% CI, 0.58–0.70) 有较低的使用任何 AF 治疗。eGFR 为 15-29 ml/min/1.73 m 2的患者调整后使用心率控制剂(aHR,0.61;95% CI,0.56 至 0.67)、华法林(aHR,0.89;95% CI,0.84 至 0.94)、和 DOAC(aHR,0.23;95% CI,0.19 至 0.27)与 eGFR >60 ml/min/1.73 m 2的患者相比。对于 eGFR <15 ml/min/1.73 m 2,这些关联甚至更强. CKD 严重程度与接受 AF 相关手术之间也存在分级关联(对比 eGFR >60 ml/min 每 1.73 m 2):eGFR 30–44 ml/min 每 1.73(aHR,0.78;95% CI,0.70 至0.87)、eGFR 15–29 ml/min/1.73 m 2(aHR,0.73;95% CI,0.61 至 0.88)和 eGFR <15 ml/min/1.73 m 2 aHR,0.48;95% CI,0.31 至 0.31 至0.74)。

结论

在新诊断 AF 的成年人中,CKD 的严重程度与较低的心率控制药物、抗凝和 AF 程序的接受有关。需要有关 AF 治疗在 CKD 人群中的有效性和安全性的更多数据来为管理策略提供信息。

更新日期:2022-02-01
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