HMN 2026: How Kidney disease increases the risk of cardiovascular events in patients with device-detected atrial fibrillation

A prespecified analysis of the NOAH-AFNET 6 trial investigated the impact of kidney function on cardiovascular outcome in patients with device-detected atrial fibrillation. Today, the findings were presented by AFNET board member Prof. Andreas Goette, St. Vincenz Hospital, Paderborn, Germany, at the annual congress of the European Heart Rhythm Association (EHRA) in Paris and has been accepted for publication in the EP Europace journal.

Patients with device-detected atrial fibrillation (DDAF) have a lower risk of stroke than patients with ECG-diagnosed atrial fibrillation (AF) and comparable stroke risk factors. Reduced kidney function is associated with higher rates of stroke and cardiovascular events in patients with AF. Whether chronic kidney disease (CKD) affects the cardiovascular treatment effects of anticoagulation in patients with DDAF is still an open question.

NOAH-AFNET 6 (Non–vitamin K antagonist Oral anticoagulants in patients with Atrial High-rate episodes), an investigator-initiated trial conducted by the AFNET, was terminated early due to the expected increase in bleeding events in patients with DDAF, while the stroke-preventing effect was smaller than expected. The main trial found that patients with DDAF have a low risk of stroke without anticoagulation. Oral anticoagulation slightly reduces the risk of stroke further but also increases the risk of major bleeding. The weak effects of anticoagulation were also found in several subgroups.

Kidney disease has been suggested as a marker for an increased stroke risk in patients with AF. This prespecified NOAH-AFNET 6 analysis compared anticoagulation with edoxaban treatment with no anticoagulation in 2,534 patients with DDAF at various stages of chronic kidney disease defined according to the 2024 Kidney Disease Improving Global Outcomes (KDIGO) criteria.

Primary outcome events (a composite of stroke, systemic embolism, or cardiovascular death) increased with increasing severity of CKD, which was driven by higher rates of cardiovascular death and systemic embolic events. Total stroke rate was low across all CKD stages. Safety events (major bleeding or death) also increased with increasing severity of CKD, with more major bleeding than death.

Prof. Goette explained, “Our analysis showed that age and kidney function are the strongest predictors of cardiovascular events, in particular cardiovascular death, in patients with DDAF and clinical stroke risk factors. The results also demonstrate that the approved dose of edoxaban retains its effectiveness across the spectrum of kidney functions tested.”

Prof. Paulus Kirchhof, AFNET board chair and principal investigator of the NOAH-AFNET 6 trial, stated, “This exploratory analysis suggests that the estimated glomerular filtration rate (eGFR), a widely available blood biomarker, could be useful to refine thromboembolic risk estimation in patients with DDAF and reduced kidney function in context with AF burden. Clearly, the findings call for independent, external validation in contemporary patients with DDAF.”

Provided by
Kompetenznetz Vorhofflimmern e.V. (AFNET)

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