Elsevier

American Heart Journal

Volume 242, December 2021, Pages 45-60
American Heart Journal

Clinical investigations
Patient characteristics, care patterns, and outcomes of atrial fibrillation associated hospitalizations in patients with chronic kidney disease and end-stage renal disease

https://doi.org/10.1016/j.ahj.2021.06.012Get rights and content

Background

Chronic Kidney Disease (CKD) and end-stage renal disease (ESRD) are associated with poor outcomes in patients with cardiovascular disease. There is a paucity of contemporary data on in-hospital outcomes and care patterns of atrial fibrillation (AF) associated hospitalizations CKD and ESRD.

Methods

Outcomes and care patterns were evaluated in GWTG-AFIB database (Jan 2013-Dec 2018), including in-hospital mortality, use of a rhythm control strategy, and oral anticoagulation (OAC) prescription at discharge among eligible patients. Generalized logistic regression models with generalized estimating equations were used to ascertain differences in outcomes. Hospital-level variation in OAC prescription and rhythm control was also evaluated.

Results

Among 50,154 patients from 105 hospitals the median age was 70 years (interquartile range 61-79) and 47.3% were women. The prevalence of CKD was 36.0% while that of ESRD was 1.6%. Among eligible patients, discharge OAC prescription rates were 93.6% for CKD and 89.1% for ESRD. After adjustment, CKD and ESRD were associated with higher in-hospital mortality (odds ratio [OR] 3.08, 95% confidence interval [CI] 1.57-6.03 for ESRD and OR 2.02, 95% CI 1.52-2.67 for CKD), lower odds of OAC prescription at discharge (OR 0.59, 95% CI 0.44-0.79 for ESRD and OR 0.84, 95% CI 0.75-0.94 for CKD) compared with normal renal function. CKD was associated with lower utilization of rhythm control strategy (OR 0.92, 95% CI 0.87-0.98) with no significant difference between ESRD and normal renal function (OR 1.32, 95% CI 0.79-1.11). There was large hospital-level variation in OAC prescription at discharge (MOR 2.34, 95% CI 2.05-2.76) and utilization of a rhythm control strategy (MOR 2.69, 95% CI 2.34-3.21).

Conclusions

CKD/ESRD is associated with higher in-hospital mortality, less frequent rhythm control, and less OAC prescription among patients hospitalized for AF. There is wide hospital-level variation in utilization of a rhythm control strategy and OAC prescription at discharge highlighting potential opportunities to improve care and outcomes for these patients, and better define standards of care in this patient population

Introduction

Atrial fibrillation (AF) is the most common arrhythmia in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD).1 Recent epidemiological studies have shown a strong association between AF and CKD/ESRD.2,3 Patients with CKD/ESRD have a higher thromboembolic risk associated with AF,4, 5, 6 and a higher bleeding risk associated with oral anticoagulation (OAC) compared with patients with a normal renal function.6,7 The 2019 focused update of the 2014 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) AF practice guidelines recommends consideration oral anticoagulation (OAC) in patients with CKD/ESRD and moderate-to-high risk of stroke as defined by a CHA2DS2-VASc score ≥2.8 However, there remains significant uncertainty regarding the optimal oral anticoagulation (direct acting OAC versus vitamin K antagonism) clinical effectiveness and bleeding risk associated with OAC in patients with CKD/ESRD.9,10 Clinical decision-making for a rate versus rhythm control approach for AF management in patients with CKD/ESRD is frequently based on an extrapolation of evidence from clinical trials that have traditionally excluded patients with CKD/ESRD.1 Given these uncertainties surrounding a rate versus rhythm control strategy and OAC use for thromboprophylaxis in AF in the setting of CKD/ESRD, it is likely that significant hospital-level practice variation exists in the management of hospitalized AF patients with CKD/ESRD. There is a paucity of real-world data on differences in patient characteristics, care patterns, and outcomes of AF hospitalization for patients with a normal renal function versus those with CKD/ESRD.

There were 3 main objectives in this analysis. First, we sought to describe baseline characteristics, in-hospital care patterns, and differences in discharge characteristics among patients hospitalized with AF stratified by renal function. Second, we sought to describe the association of renal function with in-hospital outcomes. Finally, we sought to ascertain between-hospital variation in utilization of a rhythm control strategy and prescription of OAC at discharge, stratified by renal function.

Section snippets

Study design, setting, and population

We performed a retrospective cohort study of patients ≥18 years hospitalized for a principal diagnosis of atrial fibrillation or atrial flutter (AF). We excluded patients with missing data on eGFR, dialysis history, age, sex, race, medical history, discharge disposition, and rate versus rhythm control strategy. Patients who were discharged against medical advice and those at low-volume centers with <25 AF hospitalizations were also excluded (Supplemental Figure 1).

Data source

We used data from the American

Baseline characteristics

A total of 50,154 patients from 105 hospitals were included in this study. Of these, 62.4% had a normal renal function, 36.0% had CKD, and 1.6% had ESRD. For the overall study cohort, median age was 70 (IQR 61-79) years and 47.3% were women. 83.3% of patients were White while 7.2% were Black. A large majority of patients were covered by some form of insurance while 2.3% were uninsured. Prevalent comorbidities included hypertension (75.0%), diabetes (27.5%), heart failure (25.5%), CVA/TIA

Discussion

In the current study using a large contemporary cohort of AF hospitalizations from a national quality improvement registry, there were several important and noteworthy findings. First, over a third of all patients hospitalized for AF had a diagnosis of CKD or ESRD. Second, while rates of OAC prescription at discharge approached 90% among eligible patients, CKD/ESRD was associated with significantly lower adjusted odds of OAC prescription at discharge compared with patients with a normal renal

Disclosures

This work was supported by the American Heart Association Young Investigator Seed Grant Award, The Get With The Guidelines–AFib (GWTG-AF) program is provided by the American Heart Association. GWTG-AF is sponsored, in part, by Daiiachi Sankyo, Boehringer Ingelheim, and BMS Pfizer.

The authors report the following additional disclosures: JPP receives grants for clinical research from Abbott, American Heart Association, Association for the Advancement of Medical Instrumentation, Bayer, Boston

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