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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 published in the EP Europace journal (1,2).
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. (3-10).
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 2534 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.”
References
(1) Goette A et al. Kidney disease increases the risk of cardiovascular events in patients with device-detected atrial fibrillation: NOAH-AFNET 6. Abstract at EHRA congress 2026
(2) Goette A, Lemoine MD, Fierenz A et al. Kidney disease increases the risk of cardiovascular events in patients with device-detected atrial fibrillation: NOAH-AFNET 6. Europace. 2026. DOI:10.1093/europace/euag083
(3) Kirchhof P, Toennis T, Goette A, et al. Anticoagulation with Edoxaban in Patients with Atrial High-Rate Episodes. N Engl J Med 2023; 389:1167-1179. DOI:10.1056/NEJMoa2303062.
(4) Toennis T, Bertaglia E, Brandes A, et al. The influence of Atrial High Rate Episodes on Stroke and Cardiovascular Death - An update. Europace. 2023 Jul 4;25(7). DOI:10.1093/europace/euad166.
(5) Becher N, Toennis T, Bertaglia E, et al. Anticoagulation with edoxaban in patients with long Atrial High-Rate Episodes ≥24 hours. Eur Heart J. 2024 Mar 7;45(10):837-849. DOI:10.1093/eurheartj/ehad771
(6) Lip YH, Nikorowitsch J, Sehner S et al. Oral anticoagulation in device-detected atrial fibrillation: effects of age, sex, cardiovascular comorbidities, and kidney function on outcomes in the NOAH-AFNET 6 trial. Eur Heart J. 2024 April 9. DOI:10.1093/eurheartj/ehae225
(7) Diener HC, Becher N, Sehner S, Toennis T et al. Anticoagulation in patients with device-detected atrial fibrillation with and without a prior stroke or transient ischemic attack. The NOAH-AFNET 6 trial. J Am Heart Assoc. 2024 Sep 3;13(17):e036429. DOI:10.1161/JAHA.124.036429
(8) McIntyre WF, Benz AP, Becher N, et al. Direct Oral Anticoagulants for Stroke Prevention in Patients with Device-Detected Atrial Fibrillation: A Study-Level Meta-Analysis of the NOAH-AFNET 6 and ARTESiA Trials. Circulation. 2024 Mar 26;149(13):981-988. DOI:10.1161/CIRCULATIONAHA.123.067512
(9) Schnabel RB, Benezet-Mazuecos J, Becher N, McIntyre WF et al. Anticoagulation in patients with device-detected atrial fibrillation with and without concomitant vascular disease – A combined secondary analysis of the NOAH-AFNET 6 and ARTESiA trials. Eur Heart J. 2024 Dec 7;45(46):4902-4916. DOI:10.1093/eurheartj/ehae596
(10) Becher N, Koellner G, Blomstrom-Lundqvist C, Camm AJ et al. Effects of anticoagulation in patients with device-detected atrial fibrillation and multiple stroke risk factors: A Win Ratio analysis of the NOAH-AFNET 6 trial. Eur Heart J Qual Care Clin Outcomes. 2025 Dec 19;11(8):1351-1358. DOI:10.1093/ehjqcco/qcaf087
About the Atrial Fibrillation NETwork (AFNET)
The Atrial Fibrillation NETwork is an interdisciplinary research network comprising scientists and physicians from hospitals and practices dedicated to improving the management of atrial fibrillation through coordinated research in Germany, Europe, and worldwide. Its main objective is to conduct high quality investigator-initiated clinical trials and registries on a national and international level as well as translational research projects. The AFNET continues the long-term activities of the network which has been funded by the German Federal Ministry of Research and Education over a decade. Since January 2015, specific projects and infrastructures of the AFNET are funded by the German Centre for Cardiovascular Research (DZHK), and some projects by EU research grants. AFNET has long expertise in the management of atrial fibrillation, but also provides support for work in other fields informing cardiovascular care. The results of 20 years of clinical and translational research improved the lives of patients with cardiovascular diseases and influenced treatment guidelines.
Funding of the NOAH trial: AFNET, DZHK, Daiichi Sankyo
NOAH registration: NCT 02618577, ISRCTN 17309850
Press Contact
Angelika Leute, PhD
Phone: +49 202 2623395
a.leute@t-online.de
Goette A et al. Abstract at EHRA congress 2026
Goette A, Lemoine MD, Fierenz A et al. Europace. 2026. DOI:10.1093/europace/euag083
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