Anticoagulation strategies and clinical outcomes in atrial fibrillation patients developing renal deterioration during DOAC therapy
T Chao, Y H Chan, G Y H LipAbstract
Background
Clinicians face difficult decision regarding whether to continue direct oral anticoagulants (DOACs), switch to vitamin K antagonist (VKAs), or discontinue oral anticoagulants (OACs) in patients with atrial fibrillation (AF) receiving DOAC therapy whose follow-up creatinine clearance (CrCl) falls below 15 ml/min.
Methods
We analyzed 2057 patients with non-valvular AF receiving DOAC therapy whose follow-up CrCl declines below 15 ml/min in a multicenter medical database in Taiwan. Patients were followed until the occurrence of study outcomes, death, or the end of the study period.
Results
After follow-up CrCl declined to <15ml/min. 1,456 patients (70.8%) continued DOACs, 233 (11.3%) switched to VKAs, and 368 (17.9%) discontinued OACs. Compared with OAC discontinuation, continuing DOACs was associated with a lower risk of thromboembolism (3.76%/year vs. 8.27%/year, sub-distribution hazard ratio [SHR]:0.44 [95%CI:0.28-0.69];P<.001), without differences in major bleeding or composite outcomes (Figure 1). Further subgroup analyses indicated that a lower risk of composite outcomes of continuing DOACs was observed in patients <85 years, those with a HAS-BLED score <3, prior stroke, or no history of major bleeding (P for interaction <0.05)(Figure 2). Compared with switching to VKAs, continuing DOAC therapy was associated with lower risks of major bleeding (8.45%year/ vs. 12.77%/year, SHR:0.63 [95%CI:0.46-0.87]; P=0.005) and composite outcomes (12.15%/year vs. 17.93%/year, SHR:0.69 [95%CI:0.52-0.91]; P=0.008)(Figure 1). The effect of continuing DOACs vs. switching to VKAs on clinical outcomes was consistent across most subgroups.
Conclusions
In AF patients receiving DOAC therapy whose follow-up CrCl declined to <15 mL/min, continuing DOAC therapy was better than shifting to VKA. Compared with discontinuing OACs, continuing DOAC therapy was associated with a lower risk of thromboembolism and a more favorable composite outcome in a selected patient population. The decision of continuing DOACs in this high-risk population requires individualized risk-benefit assessment and shared decision-making.Figure 1Figure 2