The Impact Of Novel Anticoagulant Therapy On Stroke Prevention In Patients With Non-Valvular Atrial Fibrillation And Chronic Kidney Disease: A Prospective Cohort Study At Tashkent State Medical University Clinics

Abstract

Background: Atrial fibrillation (AF) and chronic kidney disease (CKD) frequently coexist, creating a complex clinical scenario for stroke prevention. While vitamin K antagonists (VKAs) like warfarin have been the cornerstone of therapy, their use in CKD is challenging. Novel Oral Anticoagulants (NOACs) offer a promising alternative, but real-world data on their efficacy and safety in patients with AF and concurrent CKD, particularly in the Uzbek population, are scarce.

Objective: To compare the efficacy and safety of NOACs versus warfarin for stroke prevention in patients with non-valvular AF and stages 3-4 CKD.

Materials and Methods: A prospective cohort study was conducted from January 2021 to December 2023 at the cardiology and nephrology clinics of Tashkent State Medical University. We enrolled 412 patients with non-valvular AF and CKD (stages 3a, 3b, and 4). Patients were allocated into two groups: the NOAC group (n=228) receiving either apixaban, rivaroxaban, or dabigatran, and the warfarin group (n=184). The primary efficacy outcome was the incidence of ischemic stroke or systemic embolism. The primary safety outcome was the incidence of major bleeding as defined by the International Society on Thrombosis and Haemostasis (ISTH) criteria. Secondary outcomes included all-cause mortality, hospitalizations for heart failure, and a composite renal outcome (a sustained 40% reduction in eGFR or progression to end-stage renal disease).

Results: The mean follow-up duration was 24 months. The incidence of ischemic stroke/systemic embolism was significantly lower in the NOAC group compared to the warfarin group (2.2% vs. 5.4%; Hazard Ratio [HR] 0.49, 95% Confidence Interval [CI] 0.28-0.85; p=0.011). The rate of major bleeding was also significantly lower in the NOAC group (3.1% vs. 8.2%; HR 0.41, 95% CI 0.25-0.68; p<0.001). All-cause mortality was 5.7% in the NOAC group versus 10.9% in the warfarin group (HR 0.58, 95% CI 0.39-0.87; p=0.008). The NOAC group showed a slower decline in estimated glomerular filtration rate (eGFR) over the study period.

Conclusion: In a real-world cohort of Uzbek patients with non-valvular AF and moderate to severe CKD, treatment with NOACs was associated with a significantly lower risk of stroke or systemic embolism, major bleeding, and all-cause mortality compared to warfarin. These findings support the preferential use of appropriately dosed NOACs in this high-risk population.