Diabetes with comorbid kidney disease and/or AF significantly increases all-cause mortality and major cardiovascular events; NOACs show better renal protection and benefit for cardio/cerebrovascular risk than vitamin K antagonists
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1. Of diabetic patients, approximately __% have albuminuria?
2. Of diabetic patients, approximately __% have both albuminuria and impaired renal function?
3. Which statement is true?
4. Which statement is false?
5. In the ADVANCE trial, the RRI for all deaths in T2DM was ___% in the presence of AF, compared to no AF?
6. In the ADVANCE trial, the RRI for major cerebrovascular events in T2DM patients was ___% in the presence of AF, compared to no AF?
7. Risk for development of AF is further increased in the patient with:
8. The RELOADED study of diabetic patients with NVAF:
9. Real-world data from diabetes patients with AF show equivalent renal protection using rivaroxaban treatment compared to warfarin:
10. In the ROCKET AF trial comparing rivaroxaban against warfarin, approximately ___% of patients had T2DM?
11. Real-world data reflect consistency with the results of ROCKET AF showing benefit of rivaroxaban over warfarin for stroke/systemic embolism, major bleeding and intracranial haemorrhage in the diabetic patient with NVAF:
12. Compared to warfarin, rivaroxaban use in patients with T2DM and NVAF has been associated with lower risk of:
Anticoagulation case study – special considerations in diabetes and CKD
Patient and complaint:
68-year-old female, complains of leg pain and unsteadiness when walking
Metformin, amlodipine, atorvastatin
NVAF, diabetes, hypertension, kidney injury: eGFR = 43
It is unclear whether she has peripheral neuropathy or peripheral arterial disease. Clinical examination confirms the presence of AF with a heart rate around 70 beats per minute. She and her family are concerned about her unsteadiness and have heard that she may need oral anticoagulation.
13. Should she be anticoagulated?
View Expert Comment »
She has confirmed NVAF so we should be guided by the CHA2DS2-VASc score. When her age, sex, hypertension and diabetes are taken into account, there appears to be a strong indication for anticoagulation to prevent her having a stroke. However, her impaired kidney function needs to be carefully weighed up against the need for anticoagulants. Many clinicians are guilty of preferring an act of omission rather than an act of commission, meaning they would rather avoid anticoagulation and its attendant bleeding risk than reduce the patient’s risk of stroke.
Only males <65 years can achieve a CHA2DS2-VASc score <1
The HAS-BLED score estimates bleeding risk, but except in patients who have a marginal indication for anticoagulation, the bleeding risk never outweighs the need to anticoagulate.
14. Having decided to anticoagulate, what should be the choice of anticoagulant?
View Expert Comment »
In this setting it is inappropriate to consider aspirin at all. Aspirin has little or no effect on stroke risk and carries as great a risk of bleeding as warfarin. So, our first decision is whether to use the vitamin K antagonist (warfarin) and a NOAC. Leaving aside the issues of inconvenience, drug interactions, monitoring and dose variations with warfarin, we must be aware that NOACs are equal if not better at preventing strokes in patients with NVAF and also carry a lower risk of brain bleeds. Though cost is frequently an issue that favours warfarin, we need to be aware that the best clinical advice is to use a NOAC.
Among the NOACs we have the choice between one of two anti-factor Xa inhibitors (rivaroxaban and apixaban) and a thrombin antagonist (dabigatran). Although there were slight variations in the inclusion criteria and the results of the trials of these agents, we can conclude that as a group they are as effective as or more effective than warfarin at preventing stroke, and all have a lower risk of brain bleeding. Because there is little difference in their respective costs peripheral disease and stroke, personal preference, tolerability and ease of dosing play a role when deciding which NOAC to prescribe.
Bayer “Think diabetes”
15. Is there a treatment that could offer benefits beyond stroke prevention in this case?
View Expert Comment »
In his presentation, Professor Patel included observational data on the effects of NOACs in preventing acute kidney injury and progression to end-stage kidney failure, as well as the reduction of revascularisation and amputations in peripheral arterial disease. Though Professor Dalby stresses that observational data do not carry the same weight as the results of a randomised clinical trial, these results strongly suggest that when dealing with patients who have diabetes and NVAF, specific NOACs should be the drug of choice for those with cardiovascular disease, impaired kidney function and/or evidence of peripheral arterial disease.