Elsevier

American Heart Journal

Volume 198, April 2018, Pages 39-45
American Heart Journal

Clinical Investigation
Changes in glomerular filtration rate and outcomes in patients with atrial fibrillation

https://doi.org/10.1016/j.ahj.2017.12.017Get rights and content

Abstract

Background

Patients with kidney disease are more likely to develop atrial fibrillation (AF) than individuals with normal renal function, and more likely to suffer ischemic stroke (IS)/thromboembolism (TE). We investigated the relationship of kidney function evolution to IS/TE, mortality and bleeding in AF patients.

Methods

In a cohort of 8962 AF patients, 2653 had serum creatinine data, with 10894 patient-years of follow-up. Patients were stratified into quartiles of estimated glomerular filtration rate (eGFR) evolution (in mL/min per 1.73 m2/year).

Results

Rates of events (IS/TE, bleeding, mortality) increased with worsening eGFR by quartiles. The risk of events was particularly increased when patients in the 4th quartile were compared to others. Renal impairment per se was not an independent predictor of IS/TE but was an independent predictor of bleeding, whilst eGFR worsening was an independent predictor both for IS/TE (Hazard Ratio [HR] 1.573, 95%CI 1.160-2.134 for patients in the last quartile) and for bleeding events (HR 1.543, 95%CI 1.157-2.004). Worsening eGFR did not improve the predictive ability of the CHA2DS2VASc and HAS-BLED scores for identifying a higher risk of IS/TE or bleeding events, respectively. When the benefit of IS reduction was balanced against the increased risk of bleeding events, the net clinical benefit was positive in favor of OAC use (vs non-use) in patients with worsening eGFR.

Conclusions

Rates of IS/TE, mortality and bleeding increased with worsening eGFR >4.81 mL/min per 1.73 m2. Worsening eGFR was an independent predictor of IS/TE and of bleeding, and a better predictor of IS/TE than renal impairment in AF.

Section snippets

Methods

Between January 2000 and December 2010, 8962 patients seen in the Cardiology department in our institution with a diagnosis of AF were identified.1., 2. The regional university hospital of Tours serves approximately 400,000 inhabitants and is the only public institution in an area of about 4,000 km2. The information for each patient was extracted from computerized data of hospitalization and consultation of our institution. During follow-up, information on outcomes was recorded and we defined

Results

Of 8962 individuals with AF seen in the cardiology department, 2653 had several available serum creatinine data allowing the eGFR (expressed in mL/min per 1.73 m2) and eGFR evolution (slope of eGFR, expressed in mL/min per 1.73 m2/year) to be calculated (Figure 1). The number of samples with creatinine level assessment was 12±14 per patient (median 7, interquartile range 4-14).

Baseline characteristics are shown in Table 1. The eGFR at baseline in this population was 65.5 mL/min per 1.73 m2.

Discussion

In this large series of AF patients, our principal findings are as follows: (i) incidence rates of IS/TE, mortality and bleeding increased with worsening eGFR; (ii) worsening eGFR was an independent predictor of IS/TE and of bleeding, and a better predictor of IS/TE than renal function at baseline; (iii) worsening eGFR did not improve the predictive ability of the CHA2DS2VASc and HAS-BLED scores for identifying a higher risk of IS/TE or bleeding events; and (iv) when the benefit of IS reduction

Conclusions

Worsening renal function (rather than renal impairment) is associated with poor outcomes in individuals with AF across the whole range of renal function, as measured by eGFR. Incidence rates of IS/TE, mortality and bleeding substantially increased with worsening eGFR. Worsening eGFR was an independent predictor of IS/TE and of bleeding, and a better predictor of IS/TE than baseline renal impairment. These observations may have implications for future risk prediction tools of outcomes in AF as

Disclosures

This study has received no financial or material support.

LF has served as a speaker or consultant for Bayer, BMS/Pfizer, Boehringer Ingelheim, Medtronic and Novartis. NC has received consulting honoraria from Boston Scientific, Medtronic, St. Jude Medical, and Sorin-LivaNova. DA has received funding for conference travel and educational symposia from Astra Zeneca, Eli-Lilly, Novartis, Bayer, MSD, Amgen, Pfizer. DB has received clinical study support from Biotronik, Boston Scientific, Medtronic,

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    All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

    All of the authors have contributed to and approved the final version of the manuscript for submission.

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