Clinical outcomes and treatment patterns among Medicare patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease

• Published in: PloS one Vol. 14; no. 11; p. e0225052
• Main Authors: Wilson, Lauren E, Luo, Xuemei, Li, Xiaoyan, Mardekian, Jack, Garcia Reeves, Alessandra B, Skinner, Asheley
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 14.11.2019; Public Library of Science (PLoS)
• Subjects: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Anticoagulants - administration & dosage; Anticoagulants - therapeutic use; Apixaban; Atrial fibrillation; Atrial Fibrillation - complications; Atrial Fibrillation - therapy; Biology and Life Sciences; Bleeding; Cardiac arrhythmia; Care and treatment; Cerebral infarction; Chronic kidney failure; Cohort Studies; Comorbidity; Diagnosis; Edoxaban; Elderly patients; Employees; Evaluation; Female; Fibrillation; Geriatrics; Government programs; Health risks; Heart attack; Heart attacks; Humans; Kidney diseases; Kidneys; Legal fees; Male; Medical research; Medicare; Medicine and Health Sciences; Mortality; Multivariate Analysis; Myocardial infarction; Older people; Patient outcomes; Patients; Pharmaceutical industry; Renal Insufficiency, Chronic - complications; Renal Insufficiency, Chronic - therapy; Rivaroxaban; Social Sciences; Treatment Outcome; United States; Warfarin; United States; United States > US; New York City New York
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0225052

Patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease (CKD) have increased risk of adverse outcomes. This study evaluated treatment with oral anticoagulants and outcomes in elderly NVAF patients with CKD. Retrospective observational cohort study of US Medicare fee-for-service patients aged ≥66 years with comorbid CKD (advanced: Stage 4 and higher; less advanced: Stages 1-3) and a new NVAF diagnoses from 2011-2013. All-cause mortality, stroke, major bleeding, and myocardial infarction rates were estimated for 1 year post-NVAF diagnosis. Associations between CKD stage and outcomes were evaluated with multivariate-adjusted Cox regression. We assessed oral anticoagulant (OAC) receipt within 90 days post-NVAF diagnosis and associations between OAC receipt and outcomes. There were 198,380 eligible patients (79,681 with advanced CKD). After adjustment for age, gender, and comorbidities, advanced CKD was associated with increased mortality (Stage 5 HR 1.47; 95% CI 1.42-1.52), MI (HR 1.48; 95% CI 1.33-1.64), stroke (HR 1.23; 95% CI 1.11-1.37) and major bleed (HR 1.44; 95% CI 1.36-1.53) risks. Among Medicare Part D enrollees who survived ≥90 days post-NVAF diagnosis, 65-71% received no OACs in the first 90 days. Those receiving warfarin (HR 0.73; 95% CI 0.71-0.75) or DOACs (HR 0.52; 95% CI 0.49-0.56) within the first 90 days had reduced mortality in the period 90 days to 1 year following NVAF diagnosis compared to those without. Elderly NVAF patients with advanced CKD (Stage 4 or higher) had higher mortality risks and serious clinical outcomes than those with less advanced CKD (Stage 1-3). OAC use was low across all CKD stages, but was associated with a lower mortality risk than no OAC use in the first year post-NVAF diagnosis.