Predicting in a predicament: Stroke and hemorrhage risk prediction in dialysis patients with atrial fibrillation

Abstract

Whether to anticoagulate dialysis patients with atrial fibrillation is a common clinical dilemma with limited high-quality data to inform decision-making. While the efficacy and safety of anticoagulation for stroke prevention in dialysis patients with atrial fibrillation has long been debated and remains unclear, the more upstream issue of stroke risk assessment from atrial fibrillation has received relatively little attention.In the general population, a handful of risk scores to help predict stroke and hemorrhage risk in the setting of atrial fibrillation are widely validated and applied in clinical practice. But are they applicable to the dialysis population? The most commonly used stroke risk scores, CHADS2 and CHA2DS2-VASC, have limited validation in the dialysis population, and when validated, have shown poor performance (c-statistics <0.70). Stroke risk scores derived in the general atrial fibrillation population may perform poorly in dialysis patients for a number of reasons. Dialysis patients have unique stroke risk factors, such as chronic inflammation and vascular calcification, and a much higher competing risk of death, none of which are accounted for in current risk scores. Further complicating the dilemma of anticoagulation is hemorrhage risk, which is known to be exceedingly high in dialysis patients. Currently available hemorrhage risk scores, such as HAS-BLED, have not been validated in dialysis patients and will likely underestimate hemorrhage risk. Moving forward, risk tools specific to the dialysis population are needed to accurately assess and balance stroke and hemorrhage risks in dialysis patients with atrial fibrillation.

Prior ischemic strokes are non-inferior for predicting future ischemic strokes than CHA2DS2-VASc score in hemodialysis patients with non-valvular atrial fibrillation

“…Failure to take these risk factors into account, as well as assigning different weights of conventional risk factors in assembling an overall risk for ischemic stroke may explain why the CHA 2 DS 2 -VASc, the most commonly used stroke risk score in the general population, has limited validation in the MHD population. A literature review on stroke risk stratification by CHA 2 DS 2 -VASc in the MHD populations reported c-statistics of less than 0.70 in almost all studies [ 26 ] which are consistent with our results.…”

Atrial Fibrillation in Patients on Dialysis Therapy: Epidemiology, Prognosis and Choice of Anticoagulant Therapy

“…Некоторые исследователи считают, что проблема ФП у больных, находящихся на диализе, не находит должного внимания в плане выбора шкал для оценки риска развития тромбоэмболических осложнений и кровотечений [23]. Так, в общей популяции больных с ФП для оценки разви-тия риска инсульта и кровотечений при назначении АКТ широко используются в клинической практике шкалы, такие как CHA 2 DS 2 -VASC, HAS-BLED.…”

Syncope and Collapse Are Associated with an Increased Risk of Cardiovascular Disease and Mortality in Patients Undergoing Dialysis

“…Older age, male sex, diabetes, and hypertension were independent risk factors for ischemic and hemorrhagic strokes in patients undergoing dialysis [ 29 ]. Until now, the preventive effect of anticoagulants on the risk of stroke was not evident, and the prerequisite issue of stroke risk assessment from atrial fibrillation in patients undergoing dialysis has rarely been discussed [ 30 , 31 ]. In our study, a high incidence of stroke was noted in the SC cohort, and SC was associated with an increased risk of stroke regardless of sex, age, dialysis modality, or comorbidities ( Table 3 ).…”