This supplement was written by William T. Elliott, MD, FACP, Chair, Formulary Committee, Kaiser Permanente, California Division; Assistant Clinical Professor of Medicine, University of California-San Francisco. In order to reveal any potential bias in this publication, we disclose that Dr. Elliott reports no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. For questions and comments, please e-mail: firstname.lastname@example.org.
Don’t hesitate to treat your chronic kidney disease (CKD) patients with warfarin if they have atrial fibrillation (AF) — it is safe and effective, according to a large observational study in JAMA. In more than 24,000 patients who survived an acute myocardial infarction (MI) and had AF, 22% were treated with warfarin at discharge of which 52% had CKD stage 3 or worse (estimated glomerular filtration rate [eGFR] < 60). The composite endpoint included death, readmission due to MI or ischemic stroke, bleeding, or a combination of the above. Compared to no warfarin use, warfarin was associated with a lower risk of the composite outcome for every level of CKD and, in fact, the benefit was higher for those with lower eGFR. The risk of bleeding was not significantly higher in patients treated with warfarin in any CKD stratum with the rate of bleeding actually less in warfarin-treated patients than nontreated patients. The authors conclude that warfarin treatment was associated with a lower 1-year risk for composite outcome of death, MI, and ischemic stroke without a higher risk of bleeding in patients who had an MI and AF, and this association was not related to concurrent CKD (JAMA 2014;311:919-928). An editorialist points out that this study was done in Sweden where warfarin management is the best in world, but they still feel that this study “provides the best evidence today that vitamin K antagonists are associated with improved clinical outcomes and no significant risk of bleeding in patients with myocardial infarction and atrial fibrillation with advanced CKD” (JAMA 2014;311:913-915).
Source: By William T. Elliott, MD, FACP, Chair, Formulary Committee, Kaiser Permanente, California Division; Assistant Clinical Professor of Medicine, University of California-San Francisco.