Chronic renal disease and stroke in atrial fibrillation: balancing the prevention of thromboembolism and bleeding risk

Abstract

This editorial refers to ‘Warfarin in haemodialysis patients with atrial fibrillation: what benefit?’ by F. Yang et al. , Europace 2010, 12(12):1666–1672 Atrial fibrillation (AF) confers a substantial risk of stroke and thromboembolism, and recent guidelines have advocated a risk factor-based approach to thromboprophylaxis.1 Common risk factors in everyday clinical practice have been investigated in datasets from clinical trials and cohort studies,2,3 and have been used to formulate various risk-stratification schemes, such as the CHADS2 [Cardiac Failure, Hypertension, Age, Diabetes, Stroke (Doubled)] score.4 Given the limitations of the latter and the non-inclusion of various ‘stroke-modifier’ risk factors,5 more comprehensive stroke-risk schemes such as the CHA2DS2-VASc [Cardiac Failure, Hypertension, Age ≥75 (Doubled), Diabetes, Stroke (Doubled)—Vascular disease, Age 65–74, and Sex category (Female)] score have been proposed.6 This comprehensive risk factor-based approach has been advocated in the 2010 European Society of Cardiology (ESC) guidelines on AF management.1 Even the CHA2DS2-VASc score has been (slightly) criticized for not including some risk factors associated with thromboembolism in non-valvular AF, such as cardiomyopathies (e.g. hypertrophic cardiomyopathy), infiltrative heart disease (e.g. amyloid), and renal failure. Conditions such as cardiomyopathy and amyloid are rare and while case reports and small series have suggested that such patients are at risk of stroke,7,8 they have not been specifically studied in the large randomized trials of stroke prevention in AF, to allow assessment of its predictive value for stroke on multivariate analysis. Another important consideration is the need for simplicity in any risk-stratification scheme and to have a risk score that at least can be used in everyday clinical practice, applicable to the majority of AF patients. Patients with chronic renal disease represent a complex management problem in relation to decision-making …