Oral Anticoagulation in Patients with End Stage Renal Disease and Atrial Fibrillation
The Need to Evaluate Net Clinical Effect
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Both chronic kidney disease (CKD) and atrial fibrillation (AF) are emerging health epidemics worldwide. AF is the most common heart rhythm disorder, and the burden of this dysrhythmia is expected to increase as the population ages.1 Similarly, CKD is a disease of the elderly that is estimated to affect 40% to 50% of US adults >65 years of age in the near future.2,3 This is likely attributable to manifestations of common risk factors and pathology that eventually lead to high cardiovascular and stroke risk in patients with CKD, especially patients with AF and CKD.4,5 Unfortunately, the few observational studies that are available provide conflicting reports on the impact of therapies aimed at stroke prevention in patients with AF and CKD, leading some to question the incremental influence of AF on stroke risk6 and others to question whether any antiplatelet or anticoagulation therapy reduces stroke risk in patients with AF.7 The result is significant uncertainty and variation in the management of patients with AF and CKD.
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It is in this setting that Shih et al8 present a nationwide cohort analysis from Taiwan focused on patients with AF undergoing hemodialysis in this issue of Circulation. To better understand cardiovascular outcomes in patients with concomitant AF and end-stage renal disease (ESRD), the authors used administrative claims data to compare the risks of cardiovascular events in patients with ESRD with newly diagnosed nonvalvular AF compared with matched patients without AF. They found that AF was associated with increased risks of ischemic stroke, cardiovascular death, hospitalization for heart failure, and all-cause mortality. The authors then conducted a separate analysis accounting …