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Abstract: FR-PO372

Association of Major Adverse Cardiac Events in Patients Taking Direct Oral Anticoagulants (DOACs) in Patients with CKD

Session Information

Category: Hypertension and CVD

  • 1402 Hypertension and CVD: Clinical, Outcomes, and Trials


  • Ashley, Justin Marc, The Ottawa Hospital, Ottawa, Ontario, Canada
  • McArthur, Eric, Institute for Clinical Evaluative Sciences, London, Ontario, Canada
  • Battistella, Marisa, University Health Network, Toronto, Ontario, Canada
  • Molnar, Amber O., McMaster University, Hamilton, Ontario, Canada
  • Jun, Min, The George Institute for Global Health, UNSW Sydney, Newtown, New South Wales, Australia
  • Garg, Amit X., London Health Sciences Centre, London, Ontario, Canada
  • Mavrakanas, Thomas, McGill University, Montreal, Quebec, Canada
  • Sood, Manish M., Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

Clinical trials provide conflicting evidence for the use of DOACs in the prevention of major adverse cardiac events (MACE). Patients with chronic kidney disease (CKD) are at an exceptionally high risk for MACE. We set out to assess the association of DOAC use compared to no oral anticoagulant or warfarin, and MACE, hemorrhage and all-cause mortality in patients with CKD.


Population-based retrospective cohort study of 241, 045 eligible adults of advanced age (≥ 66 years) in Ontario, Canada from 2009-2016. A high dimensional propensity score was used to match new DOAC use to either no anticoagulant or warfarin. The study outcomes were major cardiac events (MACE), hemorrhage requiring hospitalization and all-cause mortality. DOAC exposure was modeled using Cox and Fine & Gray sub-distribution hazards models to examine the association with outcomes. Outcomes by level of kidney function, albuminuria and DOAC type were also examined.


We matched 6,039 DOAC (mean [SD] age, 77.2 [7.0] years; 44.9% women), users with a high dimensional propensity score to non-anticoagulant users. There were a total of 560 (46% DOAC users) MACE, 178 hemorrhages (47% DOAC users) and 768 (31.3% DOAC users) deaths during the follow-up time. DOAC use, compared to no anticoagulant use, was associated with a higher risk of MACE (sHR 1.20 95%CI 1.04-1.39) and hemorrhage requiring hospitalization (sHR 1.36 95%CI 1.03-1.80) whereas all-cause mortality was lower (sHR 0.74 95%CI 0.61-0.91). Among DOAC and non-anticoagulant use, the risk of hemorrhage and all-cause mortality differed by DOAC type whereas all-cause mortality differed by eGFR. We further matched 5,581 DOAC to warfarin users. There were a total of 460 (56% DOAC users) MACE, 177 hemorrhages (49% DOAC users) and 581 (61% DOAC users) deaths during the follow-up time. DOAC use, compared to warfarin use, was associated with a comparable risk of MACE, hemorrhage and all-cause mortality. Among DOAC and warfarin users, the risk of all-cause mortality but not MACE or hemorrhage differed by eGFR.


DOACs did not lower the risk of major cardiac events compared to no DOAC use or warfarin in patients with or without CKD. Further studies to determine if specific DOAC dosages reduce MACE in CKD are required.