Outcomes After Warfarin Initiation in a Cohort of Hemodialysis Patients With Newly Diagnosed Atrial Fibrillation
Outcomes After Warfarin Initiation in a Cohort of Hemodialysis Patients With Newly Diagnosed Atrial Fibrillation
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DOI：
10.1053/j.ajkd.2015.05.019
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发表时间：
2015-10-01
影响因子：
13.2
通讯作者：
Winkelmayer, Wolfgang C.
中科院分区：
文献类型：
--
作者：
Shen, Jenny I.;Montez-Rath, Maria E.;Winkelmayer, Wolfgang C.
背景：尽管华法令在大多数房颤患者中被认为可以预防缺血性卒中，但支持其在血液透析患者中使用的证据有限。我们的目标是检验在大量通过Medicare Part D获得全面处方药保险的血液透析患者中发生房颤后，华法林治疗开始后的结果，与不使用华法林的结果相关。研究设计：回顾性观察性队列研究。背景和对象：美国肾脏数据系统中接受维持性血液透析的患者，他们在2007-2011年间新诊断为房颤，接受Medicare Part D覆盖，他们没有华法林使用记录。预测因素：开始华法林治疗，由房颤事件发生后30天内的处方确定。结果：死亡，缺血性中风，出血性中风，严重胃肠道出血，结果：在12,284例新诊断的房颤患者中，1,838例(15%)在30天内开始华法林治疗；然而，约有70%的人在1年内停止使用。在意向治疗分析中，华法林的使用与缺血性卒中风险的降低(HR，0.68；95%CI，0.47-0.99)略有关联，但与其他结果无关。在AS处理分析中，华法林的使用与降低死亡率相关(HR，0.84；95%CI，0.73-0.97)。限制：观察期短，非致命性事件的数量有限，结果对更富裕的患者推广有限。结论：在发生房颤的血液透析患者中，华法林的使用与缺血性卒中风险的降低略有关联，在AS处理分析中有降低死亡率的信号。这些结果支持在血液透析患者中使用华法林的临床均衡性，并强调了需要随机试验来填补这一证据空白。(C)2015年，由国家肾脏基金会公司提供。
Background: Although warfarin is indicated to prevent ischemic strokes in most patients with atrial fibrillation (AF), evidence supporting its use in hemodialysis patients is limited. Our aim was to examine outcomes after warfarin therapy initiation, relative to no warfarin use, following incident AF in a large cohort of hemodialysis patients who had comprehensive prescription drug coverage through Medicare Part D.Study Design: Retrospective observational cohort study.Setting & Participants: Patients in the US Renal Data System undergoing maintenance hemodialysis who had AF newly diagnosed in 2007 to 2011, with Medicare Part D coverage, who had no recorded history of warfarin use.Predictor: Warfarin therapy initiation, identified by a filled prescription within 30 days of the AF event.Outcomes: Death, ischemic stroke, hemorrhagic stroke, severe gastrointestinal bleeding, and composite outcomes.Measurements: HRs estimated by applying Cox regression to an inverse probability of treatment and censoring-weighted cohort.Results: Of 12,284 patients with newly diagnosed AF, 1,838 (15%) initiated warfarin therapy within 30 days; however, similar to 70% discontinued its use within 1 year. In intention-to-treat analyses, warfarin use was marginally associated with a reduced risk of ischemic stroke (HR, 0.68; 95% CI, 0.47-0.99), but not with the other outcomes. In as-treated analyses, warfarin use was associated with reduced mortality (HR, 0.84; 95% CI, 0.73-0.97).Limitations: Short observation period, limited number of nonfatal events, limited generalizability of results to more affluent patients.Conclusions: In hemodialysis patients with incident AF, warfarin use was marginally associated with reduced risk of ischemic stroke, and there was a signal toward reduced mortality in as-treated analyses. These results support clinical equipoise regarding the use of warfarin in hemodialysis patients and underscore the need for randomized trials to fill this evidence gap. (C) 2015 by the National Kidney Foundation, Inc.