Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are becoming more prevalent in
modern society, particularly in developed countries, and their incidence increases in people
with hypertension, diabetes, and the elderly. Compared to people with each specific disease
alone, people with both AF and CKD have substantially greater rates of stroke,
cardiovascular events, and mortality.
Since 2010, four direct oral anticoagulants (DOACs) have been approved, shifting the
management of patients with AF. They have now become the new first-line therapy for
patients without valvular atrial fibrillation.
A systematic review and meta-analysis of studies reporting DOAC dosing, adherence, and
persistence in CKD and AF found that DOAC adherence and DOAC dosing were
suboptimal, and further that there was little literature regarding DOAC persistence in CKD
and AF.
An investigation of demographic and clinical factors associated with the prescribing of
DOACs was conducted in a large extract of UK primary care electronic records and it was
discovered that despite having the lowest mean age, people in the most deprived quintile
had the most comorbidities and were least likely to be anticoagulated. However, with respect
to correct DOAC dosing, the disparities in healthcare improved over five years between 2018
and 2022. Suboptimal monitoring was not associated with DOAC overdosing or
underdosing. Correct monitoring was best when conducted at six monthly intervals, and
worst at three monthly intervals. DOAC overdosing was associated with more
gastrointestinal bleeding. Dementia was the only factor associated with an increase in all
adverse events, including haemorrhagic stroke and any bleeding. Better adherence was
associated with the most deprived quintile, whilst better persistence was associated with the
least deprived quintile. Non-adherence and non-persistence were associated with adverse
events-haemorrhagic strokes, gastrointestinal bleeding, major bleeding, and any bleeding as
well as with ischaemic strokes. The likely reason for this is due to multiple of factors
including that non-adherence and non-persistence occurred after the adverse events and
that the patients involved in the adverse events had complex co-morbidities with frailty and
on other drugs which can lead to bleeding. However, we were not able to elicit statistically
significant results with this theory. Our findings agree with the new ESC 2024 guidelines of
the AF-Care pathway of personalised care, taking co-morbidities into account with DOAC
management