Balancing Act: Optimizing Anticoagulation Care in Renally-Impaired Patients with NVAF or VTE


Manesh R. Patel, MD
Richard S. Stack Distinguished Professor
Chief, Division of Cardiology
Co-Director, Duke Heart Center
Senior Investigator, Duke Clinical Research Institute
Duke University
Durham, NC
John W. Stanifer, MD, MSc
Certified Hypertension Specialist 
Director, Munson Apheresis Program, Kalkaska Dialysis Center, and Munson Dialysis Center
Founder, Kidney Companions
Munson Kidney and Hypertension Specialists 
Traverse City, MI

Statement of Need

Chronic kidney disease (CKD) is a common comorbidity among patients with non-valvular atrial fibrillation (NVAF) and/or venous thromboembolism (VTE). Paradoxically, declining kidney function increases both thromboembolic and bleeding risks in patients with these conditions, requiring a fragile balance when implementing anticoagulation therapy to prevent ischemic stroke, deep vein thrombosis, and pulmonary embolism. Adding to the complexity of decision-making is a paucity of robust study results, as patients with CKD were often excluded from large anticoagulation clinical trials for patients with NVAF and VTE. Fortunately, newer studies and a wealth of real-world experience now provide practical guidance to optimize quality of care and outcomes. In particular, some of the direct oral anticoagulants (DOACs) have shown significant safety and efficacy versus warfarin in many patients with CKD and NVAF/VTE, but these therapies are still underused or underdosed because of clinician concern for increased bleeding.

In this CME Outfitters activity, experts in cardiology and nephrology discuss the challenges of striking the ideal risk-benefit ratio in anticoagulation for renally-impaired patients with NVAF or VTE. They explore the roles that shared decision making and recognition of each patient’s social determinants of health play in improving adherence to therapies. Importantly, the faculty demonstrates how cultural humility and awareness of implicit bias, particularly in communities of color, can improve equitable care and ensure best outcomes.

Learning Objectives

At the conclusion of this activity, learners will be able to better:

  • Evaluate the efficacy, safety, and appropriate dosing of anticoagulant options for renally-impaired patients with NVAF or VTE
  • Integrate findings from randomized clinical trial (RCTs) and real-world evidence (RWE) to improve the care of patients with renal impairment and NVAF or VTE, including older patients
  • Utilize shared decision making (SDM) principles and continued follow-up to improve quality of care and patient adherence to anticoagulation therapies for patients with NVAF or VTE who are renally impaired

Financial Support

Supported by an educational grant from the Bristol Myers Squibb and Pfizer Alliance.

Target Audience

Primary care physicians, internists, family medicine physicians, nephrologists, cardiologists, vascular medicine specialists, hematologists, emergency medicine physicians, hospitalists, nurse practitioners (NPs), physician associates (PAs), and pharmacists

Credit Information

Jointly Accredited Provider

In support of improving patient care, CME Outfitters, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Interprofessional (IPCE) 0.75

This activity was planned by and for the healthcare team, and learners will receive 0.75 Interprofessional Continuing Education Credit for learning and change.

Physicians (ACCME) 0.75

CME Outfitters, LLC, designates this Enduring Material for a maximum of 0.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nurses (ANCC) 0.75

This activity is designated for 0.75 contact hours.

California Residents: This continuing nursing education activity was approved by the California Board of Registered Nursing. CME Outfitters LLC’s provider number is CEP15510.

Note to Nurse Practitioners: the content of this CNE activity pertains to Pharmacology.

Pharmacists (ACPE) 0.75

This application-based activity is approved for 0.75 contact hours (0.075 CEUs) of continuing pharmacy credit (JA0007185-0000-23-146-H01-P).

PAs (AAPA) 0.75

CME Outfitters, LLC, has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.75 AAPA Category 1 CME credits. Approval is valid until 02/01/2025. PAs should only claim credit commensurate with the extent of their participation.


Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 medical knowledge MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

MIPS Improvement Activity

Completion of this accredited CME activity meets the expectations of an Accredited Safety or Quality Improvement Program (IA_PSPA_28) for the Merit-based Incentive Payment Program (MIPS). Clinicians should submit their improvement activities by attestation via the CMS Quality Payment Program website.

Royal College MOC

Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME’s “CME in Support of MOC” program in Section 3 of the Royal College’s MOC Program.

Disclosure Declaration

Dr. Patel reports the following financial relationships:

Advisory Board: Bayer; Janssen Pharmaceuticals, Inc.; and Novartis Pharmaceutical Corporation

Grants: AstraZeneca; Bayer; Janssen Pharmaceuticals, Inc.; Mytonomy; and Procyrion, Inc.

Dr. Stanifer reports no financial relationships to disclose.


The following individuals have no financial relationships to disclose:

Marlon (Tony) Graham, MD (Peer Reviewer)
Nichole Lainhart (Planning Committee)
Warren Beckman (Planning Committee)
Susan H. Yarbrough, CHCP (Planning Committee)
Sandra Caballero, PharmD (Planning Committee)
Sharon Tordoff (Planning Committee)

Obtaining Credit

Post-tests, credit request forms, and activity evaluations must be completed online (requires free account activation), and participants can print their certificate or statement of credit immediately (70% pass rate required). This website supports all browsers except Internet Explorer for Mac.

Questions about this activity?

Call us at 877.CME.PROS (877.263.7767).


Balancing Act: Optimizing Anticoagulation Care in Renally-Impaired Patients with NVAF or VTE
Event Date: 02/01/2024