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The European Society of Cardiology (ESC) congress is the largest cardiovascular congress in the world. This year’s event also included the World Congress of Cardiology and attracted over 30,000 delegates, who gathered at the Paris Expo Porte de Versailles to participate in a programme of over 500 different sessions across the full spectrum of cardiovascular medicine.
As ever, a large amount of the data and discussion focused on prevention of stroke in patients with atrial fibrillation (AF), reflecting the huge burden of this disease around the world.
When we think about our patients with AF, it is important to remember why we prescribe anticoagulants in the first place – to protect our patients from the devastating consequences of stroke. However, protection is more than efficacy and safety, and safety is more than just bleeding risk. We also need to think about the other factors that can influence that protection, such as preserving renal function, and considering co-morbidities, dosing and adherence.
The Bayer-sponsored satellite symposium entitled ‘The bigger picture in stroke prevention and anticoagulation: Think Beyond Atrial Fibrillation’ focused on the key and interlinked topics of renal impairment and diabetes. Patients with renal impairment are at significantly increased risk of stroke, bleeding and mortality, and co-morbid diabetes further increases this risk.
Professor Peter Rossing, a diabetologist from the Steno Center in Copenhagen, Denmark, highlighted the importance of ‘looking out for’ AF in patients with diabetes and CKD because of the increased risks of kidney and heart problems. Interestingly, a separate analysis of the US MarketScan data also indicated that rivaroxaban was associated with lower risks of major adverse cardiovascular events (MACE) and major adverse limb events versus warfarin in patients with non-valvular AF and diabetes.
These interesting topics were discussed further in the interactive hub session entitled ‘The bigger picture in stroke prevention: integrating AF, kidney disease and diabetes to optimize patient care’. In this session Dr Manesh Patel and Dr Christian Ruff discussed the management of two patients, highlighting the importance of individualizing care needs to optimize protection.
Dr Manesh Patel and Dr Christian Ruff discuss a patient case
The fascinating discussions continued in a series of practical tutorials with experts closely linked to the management of patients with diabetes or renal impairment, including a nephrologist, a diabetologist, a pharmacist and a pharmacologist. All sessions emphasized the importance of considering protection in its broadest sense, and this was summed up by Professor John Camm when he said that ‘we have to take a holistic approach to patient care’.
Data from several real-world studies were presented at ESC and provided compelling new evidence to support the use of rivaroxaban in patients with renal impairment.
Exciting recent real-world evidence from the German RELOADED study was presented at ESC and focused on patients with AF and renal impairment. One analysis from this study showed that rivaroxaban and apixaban had favourable safety profiles compared with vitamin K antagonists (VKAs) in patients with AF and renal impairment. Another analysis from RELOADED supported a potentially nephroprotective effect for NOACs compared with VKAs. Significantly fewer patients receiving rivaroxaban or apixaban in this study progressed to end-stage renal disease compared with those receiving a VKA, with a more pronounced effect associated with rivaroxaban. Rivaroxaban was also associated with a reduced risk of acute kidney injury compared with VKA in patients with stage 3/4 chronic kidney disease (CKD).
The conclusions of RELOADED were echoed by data from the real-world CALLIPER study, used US claims data to look at worsening renal function in patients who had AF and stage 3/4 CKD. The data showed that acute kidney injury, kidney failure or progression to stage 5 CKD were significantly reduced with rivaroxaban compared with warfarin; this effect was maintained in patients who also had diabetes.
New data from the prospective SAFIR-AC registry compared the risk of bleeding in 1903 patients aged >80 years with AF receiving rivaroxaban or VKA. In this challenging population, rivaroxaban was associated with significantly fewer major bleeds and significantly fewer intracranial haemorrhages compared with VKA.
Overall, new data at ESC 2019 showed that anticoagulation with rivaroxaban may mitigate renal decline in patients with AF. As we increase our understanding of the relationship between AF, diabetes and renal impairment, we will be able to offer tailored treatment to these challenging patients and provide improved protection from devastating cardiovascular events.
Find out more about ESC 2019, read the abstracts and watch the presentations at the ESC website
Find out more about the diagnosis and management of atrial fibrillation at ThrombosisAdviser
VKAs or NOACs (e.g. apixaban, dabigatran, edoxaban or rivaroxaban) are recommended in patients with AF and diabetes aged >65 years with a CHA2DS2-VASc score ≥2; it is recommended to give preference to NOACs.