Hemorrhagic Versus Ischemic Risk in Patients with Atrial Fibrillation on Hemodialysis

Abstract

Background: Hemodialysis (HD) patients with atrial fibrillation (AF) have a particularly high risk of stroke and bleeding, but no high-quality evidence-based recommendations exist to properly manage these patients. Objectives:We aim to evaluate the ischemic versus the hemorrhagic risk in a HD population with AF. Methods:We selected incident patients that started hemodialysis between 2011 and 2015. All patients that had AF before HD, or developed AF during the follow-up, were included. Both CHA 2 DS 2 -VASC and HAS-BLED scores were calculated at the time of beginning of HD or AF diagnosis and correlated with the outcomes using a logistic regression model. The outcomes were hemorrhagic events, ischemic events and death related to any of these events. A p-value < 0.05 was set as statistically significant.Results: Forty-six patients were included. Most of them had had AF before they started hemodialysis. Twentytwo patients were on oral anticoagulation (OAC). There was no significant difference between the incidence of ischemic and hemorrhagic events, regardless of the use of OAC. Previous stroke, transient ischemic attack, and thromboembolic event significantly increased the risk of an ischemic event (OR 6.78, p=0.028). Conclusions:In this population, we did not observe any difference between the incidence of ischemic and hemorrhagic events, which was also true in patients with OAC. Therefore, the benefit of OAC in such patients remains questionable. However, patients with previous stroke, transient ischemic attack, or thromboembolic event seem to have a higher risk of new ischemic events and might benefit from anticoagulation.

Atrial Fibrillation and Hemodialysis – Should we Anticoagulate These Patients? Ischemic Versus Hemorrhagic Risk

“…4 The results have been divergent in different studies in relation to the indication of OAC in patients with AF and chronic renal failure. Sousa et al, 5 in a study recently published in this journal, evaluated the ischemic versus hemorrhagic risk in patients with AF on hemodialysis, and they did not observe any difference between the incidence of ischemic and hemorrhagic events, notwithstanding the use of OAC. The study was observational and retrospective, and there was no correlation between the CHA2DS2VASC score and the risk of ischemic events.…”

“…Nevertheless, patients who had previous stroke or thromboembolic events appear to have a greater risk of new events and may benefit from OAC. 5 Other authors have observed a relationship between increased CHA2DS2VASC score values and the risk of ischemic stroke in patients with AF on hemodialysis, such as Chao et al, 6 and Wang et al, 7 Pokorney et al, 8 evaluated patients with severe chronic renal failure and AF. Their cohort included 8410 patients, and they did not observe any association between the use of OAC and reduced stroke or death in this group, although OAC was associated with increased hospitalization for bleeding or intracranial hemorrhagic.…”