Antithrombotic Strategies in Advanced Chronic Kidney Disease: Real-World Comparison of Oral Anticoagulation Alone vs Dual Antithrombotic Therapy.

Abstract

To compare the effectiveness and safety of oral anticoagulant (OAC) monotherapy vs dual antithrombotic therapy (OAC plus a single antiplatelet) in patients with advanced chronic kidney disease (CKD) with atrial fibrillation (AF) and coronary artery disease (CAD). We conducted a retrospective cohort study using TriNetX data from March 1, 2005, through April 1, 2024. Adults with advanced CKD (stages 4 and 5 or dialysis dependent) with AF and CAD were included. Patients treated with OAC monotherapy or dual therapy were matched 1:1 by propensity scores and observed for 12 months. Efficacy outcomes included major adverse cardiovascular events, ischemic stroke, and acute myocardial infarction; safety outcomes were major bleeding, minor bleeding, and intracranial hemorrhage. Of 57,447 patients (13,920 OAC monotherapy; 43,527 dual therapy), 12,589 matched pairs were analyzed. At 12 months, OAC monotherapy was associated with lower risks of major adverse cardiovascular events (hazard ratio [HR], 0.84; 95% CI, 0.81 to 0.88), acute ischemic stroke (HR, 0.67; 95% CI, 0.62 to 0.73), and acute myocardial infarction (HR, 0.48; 95% CI, 0.44 to 0.53). Safety outcomes also favored OAC monotherapy, with reduced risk of major bleeding (2.5% vs 3.1%; risk difference [RD], -0.5%; 95% CI, -0.9 to -0.1%), minor bleeding (15.5% vs 19.8%; RD, -4.3%; 95% CI, -5.2 to -3.2%), and intracranial hemorrhage (1.4% vs 1.9%; RD, -0.4; 95% CI, -0.7 to -0.1%). In patients with advanced CKD, AF, and CAD, OAC monotherapy was associated with lower cardiovascular and bleeding risks compared with dual therapy, supporting its use as a safer and effective strategy in this high-risk population.