NOACs better than VKAs at preventing deaths, CVD in AF patients with or without impaired kidney

For atrial fibrillation (AF) patients with normal or impaired renal function, use of nonvitamin K antagonist oral anticoagulants (NOACs) results in improved outcomes relative to vitamin K antagonist (VKA) therapy, suggests a study presented at ESC 2024.

In addition, “increasing creatinine clearance (CrCl) was associated with a decreased risk of adverse clinical events, including all-cause death and cardiovascular disease (CVD) in anticoagulated AF patients,” according to the authors led by Dr Yang Chen from Liverpool Centre for Cardiovascular Science at University of Liverpool in the UK.

Chen and his team analysed anticoagulated patients with AF from the prospective GLORIA-AF registry and calculated CrCl for renal function using the Cockcroft-Gault equation. They used a restricted cubic spline (RCS) to examine the nonlinear association between CrCl and adverse clinical events. Such association was then compared between NOAC and VKA users.

Cox regression models were used to compare the efficacy of NOAC versus VKA, and hazard ratios (HRs) were calculated for indicators.

Finally, the investigating team followed-up patients for the composite outcome (ie, all-cause death, thromboembolism, and major bleeding), all-cause mortality, cardiovascular disease (CVD), major bleeding, myocardial infarction (MI), and stroke. [Chen Y, et al, ESC 2024]

A total of 10,594 patients with AF (mean age 70.35 years, 55 percent male, 73 percent on NOAC) were included in the study. In RCS analysis, increasing CrCl in patients with CrCl <80 mL/min significantly correlated with reduced risks of all-cause death, CVD, and the composite outcomes. 

Multivariate Cox models revealed that AF patients treated with NOAC had a lower risk of all-cause death (HR, 0.68, 95 percent confidence interval [CI], 0.58−0.78), composite outcomes (HR, 0.77, 95 percent CI, 0.68−0.86), CVD (HR, 0.7, 95 percent CI, 0.56−0.87), and major bleeding (HR, 0.74, 95 percent CI, 0.61−0.91).

Renal function

For patients with CrCl >95 mL/min, NOAC use resulted in a lower risk of all-cause death (HR, 0.56, 95 percent CI, 0.38−0.82), composite outcomes (HR, 0.68, 95 percent CI, 0.51−0.91), and major bleeding (HR, 0.54, 95 percent CI, 0.35−0.85) relative to VKA.

Similarly, NOAC therapy correlated with a reduced risk of all-cause death (HR, 0.47, 95 percent CI, 0.28−0.81), composite outcomes (HR, 0.56, 95 percent CI, 0.35−0.89), and CVD (HR, 0.43, 95 percent CI, 0.20−0.90) among patients with CrCl <30 mL/min.

For patients with moderate CrCl, outcomes did not differ significantly between NOAC and VKA users.

Notably, the risks of all-cause death, major bleeding, and the composite outcome were higher among non-Asian patients with AF, according to Chen. However, no significant association was observed between ethnic groups and renal function.

“In this large prospective global registry, NOACs were associated with better outcomes compared with VKA in [AF] patients with normal or impaired renal function,” Chen said.

“Renal function, as assessed by CrCl, plays a crucial role in determining the efficacy and safety of oral anticoagulant therapy in patients with AF,” he noted.