Mild kidney disease as a risk factor for major bleeding in patients with atrial fibrillation undergoing percutaneous coronary stenting

Sergio Manzano-Fernández; Francisco Cambronero; Cesar Caro-Martínez; Jose A. Hurtado-Martínez; Francisco Marín; Francisco J. Pastor-Pérez; Alicia Mateo-Martínez; Marianela Sánchez-Martínez; Eduardo Pinar-Bermúdez; Mariano Valdés

doi:10.1160/TH11-08-0524

Thrombosis and Haemostasis, Inhaltsverzeichnis

Thromb Haemost 2012; 107(01): 51-58
DOI: 10.1160/TH11-08-0524

Blood Coagulation, Fibrinolysis and Cellular Haemostasis

Schattauer GmbH

Mild kidney disease as a risk factor for major bleeding in patients with atrial fibrillation undergoing percutaneous coronary stenting

Autoren

Sergio Manzano-Fernández

¹Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain
Francisco Cambronero

¹Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain
Cesar Caro-Martínez

¹Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain
Jose A. Hurtado-Martínez

¹Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain
Francisco Marín

¹Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain
Francisco J. Pastor-Pérez

¹Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain
Alicia Mateo-Martínez

¹Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain
Marianela Sánchez-Martínez

¹Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain
Eduardo Pinar-Bermúdez

¹Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain
Mariano Valdés

¹Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain

Abstract

Summary

Bleeding risk is increased in patients with atrial fibrillation (AF) and moderate to severe kidney disease (KD); however, the implication of mild KD on bleeding remains unclear. The aim of this study was to determine whether the presence of mild KD increases risk for major bleeding (MB) in patients with AF undergoing percutaneous coronary intervention with stent implantation (PCI-S). Two hundred eighty-five patients were included. Patients were classified into three kidney function groups: moderate to severe KD (n=91; <60 ml/min/1.73 m²), mild KD (n=139; 60–89 ml/min/1.73 m²) and non-KD (n=55; ≥90 ml/min/1.73 m²). Estimated glomerular filtration rate was calculated using the simplified Modification of Diet in Renal Disease equation. Patients were followed for one year, and the occurrence of MB was obtained in all. A total of 28 patients (9.8%) presented MB. MB complications examined as a function of KD groups revealed that there was a graded increase in MB with worsening renal function (non KD=1.8%, mild KD=7.9%, moderate to severe KD=17.6%; p <0.001). Multivariable Cox regression analysis showed that mild KD was associated with nearly a 2.5-fold (2.43 95% confidence interval 1.11–5.34, p=0.039) increase in the risk of MB as compared with non-KD patients. Other independent predictors of MB were moderate-severe KD, anaemia and triple antithrombotic therapy after PCI-S (C-index=0.76). In this population, mild KD confers a significantly increase in the risk for MB complications. Future studies should assess the potential role of incorporating mild KD into the bleeding risk scales to improve the stratification of these patients.

Keywords

Kidney disease - bleeding - atrial fibrillation - coronary stenting

Volltext

Referenzen

References
1 Eikelboom JW, Mehta SR, Anand SS. et al. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation 2006; 114: 774-782.
2 Feit F, Voeltz MD, Attubato MJ. et al. Predictors and impact of major hemorrhage on mortality following percutaneous coronary intervention from the REPLACE-2 Trial. Am J Cardiol 2007; 100: 1364-1369.
3 Kinnaird TD, Stabile E, Mintz GS. et al. Incidence, predictors, and prognostic implications of bleeding and blood transfusion following percutaneous coronary interventions. Am J Cardiol 2003; 92: 930-935.
4 Abdelhafiz AH, Myint MP, Tayek JA. et al. Anemia, hypoalbuminemia, and renal impairment as predictors of bleeding complications in patients receiving anticoagulation therapy for nonvalvular atrial fibrillation: a secondary analysis. Clin Ther 2009; 31: 1534-1539.
5 Manzano-Fernandez S, Marin F, Pastor-Perez FJ. et al. Impact of chronic kidney disease on major bleeding complications and mortality in patients with indication for oral anticoagulation undergoing coronary stenting. Chest 2009; 135: 983-990.
6 Dimarco JP, Flaker G, Waldo AL. et al. Factors affecting bleeding risk during anticoagulant therapy in patients with atrial fibrillation: observations from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Am Heart J 2005; 149: 650-656.
7 Camm AJ, Kirchhof P, Lip GY. et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31: 2369-2429.
8 Cairns JA, Connolly S, McMurtry S. et al. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter. Can J Cardiol 2011; 27: 74-90.
9 Lip GY, Huber K, Andreotti F. et al. Antithrombotic management of atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing coronary stenting: executive summary--a Consensus Document of the European Society of Cardiology Working Group on Thrombosis, endorsed by the European Heart Rhythm Association (EHRA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2010; 31: 1311-1318.
10 Lip GY, Huber K, Andreotti F. et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary intervention/ stenting. Thromb Haemost 2010; 103: 13-28.
11 Lip GY, Andreotti F, Fauchier L. et al. Bleeding risk assessment and management in atrial fibrillation patients: a position document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis. Europace 2011; 13: 723-746.
12 Levey AS, Bosch JP, Lewis JB. et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999; 130: 461-470.
13 Mehran R, Rao SV, Bhat DL. et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation 2011; 123: 2736-2747.
14 Reinecke H, Brand E, Mesters R. et al. Dilemmas in the management of atrial fibrillation in chronic kidney disease. J Am Soc Nephrol 2009; 20: 705-711.
15 Marinigh R, Lane DA, Lip GY. Severe renal impairment and stroke prevention in atrial fibrillation: implications for thromboprophylaxis and bleeding risk. J Am Coll Cardiol 2011; 57: 1339-1348.
16 Boccardo P, Remuzzi G, Galbusera M. Platelet dysfunction in renal failure. Semin Thromb Hemost 2004; 30: 579-589.
17 Gangji AS, Sohal AS, Treleaven D. et al. Bleeding in patients with renal insufficiency: a practical guide to clinical management. Thromb Res 2006; 118: 423-428.
18 Stangier J, Rathgen K, Stahle H. et al. Influence of renal impairment on the pharmacokinetics and pharmacodynamics of oral dabigatran etexilate: an open-label, parallel-group, single-centre study. Clin Pharmacokinet 2010; 49: 259-268.
19 Eriksson BI, Quinlan DJ, Weitz JI. Comparative pharmacodynamics and pharmacokinetics of oral direct thrombin and factor xa inhibitors in development. Clin Pharmacokinet 2009; 48: 1-22.
20 Reddan D, Szczech LA, O'Shea S. et al. Anticoagulation in acute cardiac care in patients with chronic kidney disease. Am Heart J 2003; 145: 586-594.
21 Best PJ, Steinhubl SR, Berger PB. et al. The efficacy and safety of short- and long-term dual antiplatelet therapy in patients with mild or moderate chronic kidney disease: results from the Clopidogrel for the Reduction of Events During Observation (CREDO) trial. Am Heart J 2008; 155: 687-693.
22 James S, Budaj A, Aylward P. et al. Ticagrelor versus clopidogrel in acute coronary syndromes in relation to renal function: results from the Platelet Inhibition and Patient Outcomes (PLATO) trial. Circulation 2010; 122: 1056-1067.
23 Small DS, Wrishko RE, Ernest CS. et al. Prasugrel pharmacokinetics and pharmacodynamics in subjects with moderate renal impairment and end-stage renal disease. J Clin Pharm Ther 2009; 34: 585-594.
24 Keltai M, Tonelli M, Mann JF. et al. Renal function and outcomes in acute coronary syndrome: impact of clopidogrel. Eur J Cardiovasc Prev Rehabil 2007; 14: 312-318.
25 Doyle BJ, Rihal CS, Gastineau DA. et al. Bleeding, blood transfusion, and increased mortality after percutaneous coronary intervention: implications for contemporary practice. J Am Coll Cardiol 2009; 53: 2019-2027.
26 Pisters R, Lane DA, Nieuwlaat R. et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010; 138: 1093-1100.
27 Lip GY, Frison L, Halperin JL. et al. Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol 2011; 57: 173-180.
28 Singer DE, Chang Y, Fang MC. et al. The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Ann Intern Med 2009; 151: 297-305.
29 Manzano-Fernandez S, Pastor FJ, Marin F. et al. Increased major bleeding complications related to triple antithrombotic therapy usage in patients with atrial fibrillation undergoing percutaneous coronary artery stenting. Chest 2008; 134: 559-567.
30 Khurram Z, Chou E, Minutello R. et al. Combination therapy with aspirin, clopidogrel and warfarin following coronary stenting is associated with a significant risk of bleeding. J Invasive Cardiol 2006; 18: 162-164.
31 DeEugenio D, Kolman L, DeCaro M. et al. Risk of major bleeding with concomitant dual antiplatelet therapy after percutaneous coronary intervention in patients receiving long-term warfarin therapy. Pharmacotherapy 2007; 27: 691-696.
32 Karjalainen PP, Porela P, Ylitalo A. et al. Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting. Eur Heart J 2007; 28: 726-732.
33 Nguyen MC, Lim YL, Walton A. et al. Combining warfarin and antiplatelet therapy after coronary stenting in the Global Registry of Acute Coronary Events: is it safe and effective to use just one antiplatelet agent?. Eur Heart J 2007; 28: 1717-1722.
34 Ruiz-Nodar JM, Marin F, Sanchez-Paya J. et al. Efficacy and safety of drug-eluting stent use in patients with atrial fibrillation. Eur Heart J 2009; 30: 932-939.