Chronic kidney disease in patients with atrial fibrillation: Effects on outcomes with and without early rhythm control.

N. Schenker (Hamburg)¹, K. Borof (Hamburg)², C. Schmidt-Lauber (Hamburg)³, A. Goette (Paderborn)⁴, G. Breithardt (Münster)⁵, J. Camm (London)⁶, H. J. Crijns (Maastricht)⁷, L. Eckardt (Münster)⁸, A. Elvan (Zwolle)⁹, L. Fabritz (Hamburg)¹⁰, I. Van Gelder (Groningen)¹¹, M. Gulizia (Catania)¹², L. Haegeli (Zürich)¹³, H. Heidbuchel (Antwerpen)¹⁴, J. Kautzner (Staré Město)¹⁵, M. Lemoine (Hamburg)², A. Ng (Leicester)¹⁶, R. Schnabel (Hamburg)¹⁷, A. Suling (Hamburg)¹⁸, L. Szumowsky (Warschau)¹⁹, S. Thermistoclakis (Venice)²⁰, P. E. Vardas (Heraklion)²¹, K. Wegscheider (Hamburg)¹⁸, S. Willems (Hamburg)²², A. Zapf (Hamburg)¹⁸, A. Metzner (Hamburg)¹, A. Rillig (Hamburg)¹, P. Kirchhof (Hamburg)^10
1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie Hamburg, Deutschland; ²Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ³Universitätsklinikum Hamburg-Eppendorf III. Medizinische Klinik und Poliklinik Nephrologie/Rheumatologie Hamburg, Deutschland; ⁴St. Vincenz-Krankenhaus GmbH Medizinische Klinik II, Kardiologie Paderborn, Deutschland; ⁵Münster, Deutschland; ⁶St. Georges Hospital Cardiovascular Research Group London, Großbritannien; ⁷Maastricht UMC+Heart+Vascular Center Department of Cardiology Maastricht, Niederlande; ⁸Universitätsklinikum Münster Klinik für Kardiologie II - Rhythmologie Münster, Deutschland; ⁹Isala Klinieken Weezenlanden Zwolle, Niederlande; ¹⁰Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Lübeck, Deutschland; ¹¹University Medical Center Groningen Department of Cardiology Groningen, Niederlande; ¹²13 Cardiology Division, Garibaldi-Nesima Hospital Catania, Italien; ¹³Zürich, Schweiz; ¹⁴University of Antwerp Department of Cardiology Antwerpen, Belgien; ¹⁵Charles University Department of Cardiology Staré Město, Tschechische Republik; ¹⁶Leicester, Großbritannien; ¹⁷Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland; ¹⁸Universitätsklinikum Hamburg-Eppendorf Zentrum für Experimentelle Medizin, Institut für Medizinische Biometrie und Epidemiologie Hamburg, Deutschland; ¹⁹Warschau, Polen; ²⁰Venice, Italien; ²¹Heraklion University Hospital Department of Cardiology Heraklion, Griechenland; ²²Asklepios Klinik St. Georg Kardiologie & internistische Intensivmedizin Hamburg, Deutschland

Background:

Atrial fibrillation (AF) and chronic kidney disease (CKD) increase cardiovascular risk, while early rhythm control reduces it.

Objective:

To determine the effects of CKD on cardiovascular events and on early rhythm control therapy in the EAST-AFNET 4 trial.

Methods:

This predefined secondary analysis of EAST-AFNET 4 assessed the effect of CKD defined by estimated glomerular filtration rate (eGFR) as continuous parameter and by kidney function stages. The primary outcome consisted of cardiovascular death, stroke, hospitalization for worsening heart failure or acute coronary syndrome. The safety outcome was a composite of death, stroke or serious adverse events related to rhythm control therapy.

Results:

In 2742/2789 (98.3%) patients with baseline creatinine concentrations, 23% had CKD (eGFR <60ml/min/1.73m²). Patients with CKD were older (CKD 74±7.4, no CKD 69±8.3 years, p<0.001) and had higher CHA₂DS₂-VASc scores (CKD 4±1.4, no CKD 3.2±1.2, p<0.001). Patients with better kidney function experienced less primary outcome events over 5.1 years of follow-up (hazard ratio HR 0.98 [0.97;0.99] per ml eGFR decrease). Early rhythm control reduced the primary outcome in patients without CKD (early rhythm control 3.4%/100 patient-years, usual care 4.1%/100 patient-years, HR 0.84, p<0.001) and patients with CKD (early rhythm control 5.8%/100 patient-years, usual care 8.5%/100 patient-years, HR 0.67, p<0.001, p_interaction=0.133). CKD was associated with increased safety outcomes without interaction with early rhythm control (p_interaction=0.927).

Conclusion:

Chronic kidney disease increases the risk of cardiovascular events in patients with recently diagnosed atrial fibrillation and stroke risk factors. Early rhythm control retains its effectiveness with and without chronic kidney disease.

Table 1:

	GFR ≥ 60ml/min/1.73m²		GFR < 60ml/min/1.73m²
	Early rhythm control	Usual care	Early rhythm control	Usual care
First primary outcome - events/person-yr (incidence/100 person-yr)	173/5068 (3.4)	204/4949 (4.1)	72/1238 (5.8)	110/1293 (8.5)