Abstract
BackgroundWe tested whether CHA2DS2-VASc and/or HAS-BLED scores better predict ischemic stroke and major bleeding, respectively, than their individual components in maintenance hemodialysis (MHD) patients with atrial fibrillation (AF).MethodsA retrospective cohort study of a clinical database containing the medical records of 268 MHD patients with non-valvular AF (167 women, mean age 73.4 ± 10.2 years). During the median follow-up of 21.0 (interquartile range, 5.0–44.0) months, 46 (17.2%) ischemic strokes and 24 (9.0%) major bleeding events were reported.ResultsAlthough CHA2DS2-VASc predicted ischemic stroke risk in the study population (adjusted HR 1.74 with 95% CI 1.23–2.46 for each unit of increase in CHA2DS2-VASc score, and HR of 5.57 with 95% CI 1.88–16.49 for CHA2DS2-VASc score ≥ 6), prior ischemic strokes/transient ischemic attacks (TIAs) were non-inferior in both univariate and multivariate analyses (adjusted HR 8.65 with 95% CI 2.82–26.49). The ROC AUC was larger for the prior ischemic stroke/TIA than for CHA2DS2-VASc. Furthermore, the CHA2DS2-VASc score did not predict future ischemic stroke risks in study participants who did not previously experience ischemic strokes/TIAs (adjusted HR 1.41, 95% CI: 0.84–2.36). The HAS-BLED score and its components did not have predictive abilities in discriminating bleeding risk in the study population.ConclusionsPrevious ischemic strokes are non-inferior for predicting of future ischemic strokes than the complete CHA2DS2-VASc score in MHD patients. CHA2DS2VASc scores are less predictive in MHD patients without histories of CVA/TIA. HAS-BLED scores do not predict major bleeding in MHD patients. These findings should redesign approaches to ischemic stroke risk stratification in MHD patients if future large-scale epidemiological studies confirm them.
Highlights
Atrial fibrillation (AF) is a common problem in endstage kidney disease (ESKD) patients receiving maintenance hemodialysis (MHD) treatment [1,2,3] that increases the risk of cerebrovascular accident (CVA) and death [3, 4]
The causes of atrial fibrillation (AF) in MHD patients include common risk factors for both AF and ESKD (e.g. age, hypertension, diabetes, congestive heart failure (CHF)) as well as risk factors directly related to dialysis and discussed elsewhere [5, 6]
The patients with major bleeding events had lower Kt/V and higher functional activity compared to patients without major bleeding events, with no statistically significant differences in demographics, comorbidities, time since AF diagnosis, warfarin, enoxaparin and/or antiplatelets use, International normalized ratio (INR) levels and HAS-BLED scores between the groups with and without major bleeding events (Table 2)
Summary
Atrial fibrillation (AF) is a common problem in endstage kidney disease (ESKD) patients receiving maintenance hemodialysis (MHD) treatment [1,2,3] that increases the risk of cerebrovascular accident (CVA) and death [3, 4]. The provision of chronic anticoagulation drugs to prevent ischemic stroke, which is recommended in a general population with AF, is not always recommended in MHD patients [8,9,10]. The HAS-BLED score was developed and validated in the general population to assess the annual risk of significant bleeding in patients with atrial fibrillation [14]. We tested whether CHA2DS2-VASc and/or HAS-BLED scores better predict ischemic stroke and major bleeding, respectively, than their individual components in maintenance hemodialysis (MHD) patients with atrial fibrillation (AF)
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