Practice nurses should weigh up risks and benefits before initiating anticoagulants as these may increase risk of ischaemic stroke and haemorrhage in chronic kidney disease patients, researchers have said.
A team from London, Surrey and New York found that CKD patients on anticoagulants were almost three times more likely to suffer a stroke as those who were not, and over twice as likely to experience a haemorrhage. The incidence of stroke in patients on anticoagulants was 4.6 per 100 person years, compared to 1.5 in those who were not.
They noted, however, that death from all causes was reduced in CKD patients on anticoagulants, suggesting that this ‘paradoxical’ finding may be due to anticoagulants leading to a lower rate of fatal strokes or a reduced number of myocardial events.
The study looked at just over 2,400 patients over the age of 65 with chronic kidney disease and a new diagnosis of AF who were taking anticoagulants.
The CKD patients were matched with AF patients who were not taking anticoagulants, and followed up for an average of just over 500 days. Just over 70% of the patients were on vitamin K antagonists and the remainder were on DOACs or low molecular weight heparin.
The researchers said in the paper: ‘For the general population, overwhelming evidence from large scale randomised controlled trials supports oral anticoagulation in the context of atrial fibrillation for stroke thromboprophylaxis, and this has been universally adopted in clinical practice guidelines.
‘However, this may not apply in patients with atrial fibrillation and concurrent chronic kidney disease.’
They added: ‘Given the present lack of guidelines, the decision to start anticoagulant treatment in patients with new onset atrial fibrillation should be made on an individual basis, weighing up the known risks and potential benefits and, where possible, taking into account patients’ wishes.’
Dr Shankar Kumar, lead author and academic clinical fellow and ST1 in radiology at University College London Hospitals NHS Foundation Trust, told Nursing in Practice that the most pressing need at the moment is more studies in the field in order to inform decision making going forward.
Until then, he said that ‘weighing up the known risk factors and taking into account the benefits and risks on an individualised basis’ was the most important thing for primary care to do.