Warfarin and Stroke Outcomes in Hemodialysis Patients with Atrial Fibrillation

Abstract

The prevalence of atrial fibrillation in ESRD is extremely high, reaching 27%,1 and fibrillation, as in the general population, also is associated with increased mortality in hemodialysis patients.2 A large number of trials show the usefulness of oral anticoagulation therapy1 for primary and secondary prevention of stroke in patient populations with atrial fibrillation absent ESRD.3 Recently, a large study demonstrated the superiority of oral anticoagulation therapy compared with the combination of clopidogrel plus aspirin with regard to stroke prevention, with no added risk of bleeding.4 Even trials performed in patients with high hemorrhagic risk who took warfarin, particularly the elderly, show that benefits of treatment exceed the risks when the international normalized ratio (INR) is monitored correctly. The decision to use oral anticoagulation therapy, particularly warfarin, in patients with atrial fibrillation involves weighing the risk of a thromboembolic event without therapy, or with inadequate anticoagulation, against the risk of a hemorrhagic event on therapy, particularly over-anticoagulation. Efficacy and safety of anticoagulation in atrial fibrillation depend on maintaining the INR between 2 and 3,5 as recommended by most practice guidelines.6 Recently an INR of 3.0 to 3.4 has been proposed to achieve optimal anticoagulation intensity in patients with atrial fibrillation.7 However, dialysis populations …