The impact of chronic kidney disease on the antithrombotic strategies and outcomes in patients with acute coronary syndromes and atrial fibrillation: Insights from STAR-ACS study.

Background: Patients with acute coronary syndrome (ACS) and atrial fibrillation (AF) (ACS + AF) face elevated risks of thrombotic and bleeding events, especially with comorbid chronic kidney disease (CKD). Limited research has assessed the combined influence of CKD in this high-risk population. Methods: This first subanalysis of STAR-ACS study included 445 Japanese ACS + AF patients, stratified by CKD status (eGFR < vs. ≥ 60 mL/min/1.73 m Results: CKD prevalence was high at 56.4 %. While ratio of dual antiplatelet therapy had drastically decreased by two years, there was no significant difference between CKD (+) and (-) groups. In contrast, among anticoagulants, warfarin was preferably used in CKD (+) group, compared to CKD (-) group, remaining stable for 2 years. Direct oral anticoagulants (DOACs) were prescribed less frequently in CKD patients, with rivaroxaban usage notably lower in CKD (+), while apixaban usage numerically increased in CKD patients. Moreover, CKD was associated with a higher cumulative incidence of adverse outcomes, although this was not statistically significant. However, in DOACs-treated patients, CKD was significantly linked to poorer outcomes, with higher eGFR levels correlating with reduced risk. Conclusions: This real-world data of ACS + AF patients indicated the significant influence of CKD on anticoagulant choice and on the worse outcome trends. These findings highlight the need for tailored antithrombotic strategies in patients with ACS, AF, and CKD to mitigate bleeding and thrombotic risks.