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Abstract: FR-OR26

Stroke and Bleeding Risk Among US Veterans with Preexisting Atrial Fibrillation Transitioning to ESRD

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis

Authors

  • Wenziger, Cachet, VA Long Beach Healthcare System, Long Beach, California, United States
  • Sy, John, VA Long Beach Healthcare System, Long Beach, California, United States
  • Marroquin, Maria V., VA Long Beach Healthcare System, Long Beach, California, United States
  • Kalantar-Zadeh, Kamyar, Harold Simmons Center for Kidney Disease Research and Epidemiology, Orange, California, United States
  • Kovesdy, Csaba P., Memphis VA Medical Center, Memphis, Tennessee, United States
  • Streja, Elani, VA Long Beach Healthcare System, Long Beach, California, United States
Background

Anticoagulation has been the mainstay of stroke prevention among patients with atrial fibrillation (AF). However, end stage renal disease (ESRD) patients on hemodialysis are at higher risk of bleeding and stroke outcomes, even without anticoagulation. It is unclear if patients should be continued on anticoagulation at the time of transition to ESRD.

Methods

We retrospectively examined a cohort consisting of 29,054 pre-dialysis US veterans that had a diagnosis of AF prior to transition to ESRD without a history of stroke. Patients were first stratified by CHA2DS2-VASC and modified HAS-BLED scores, ascertained at the time of transition. Prescriptions for warfarin were determined 180 days prior to and 90 days post transition. Incidence Rate Ratios (IRR) for stroke and bleeding events prior to ESRD transition stratified by warfarin vs no warfarin across risk scores were estimated with Poisson regression.

Results

The median age was 77±9 years, 4% were female, 85% were white, and 13% were African American. The median (IQR) CHA2DS2-VASC and HAS-BLED scores were 7 (5,8) and 2 (2,3), respectively. Stroke rates by CHA2DS2-VASC scores ranged from 0.67 (scores 0/1/2) to 4.27 (score 9) per 100 pt-years while bleeding rates by HAS-BLED scores ranged from 6.83 (score 0/1) to 46.3 (score 7) per 100 pt-years (Figure). Those with a CHA2DS2-VASC score of 0/1/2, had a stroke IRR of 0.28 (95% CI: 0.09-0.90, p=0.03) favoring no warfarin. Among patients with other CHA2DS2-VASC scores, there was no difference in stroke risk between warfarin and non-warfarin users. No difference was also seen in bleeding risk among warfarin vs non-warfarin users by HAS-BLED score.

Conclusion

In low stroke risk individuals (CHA2DS2-VASC score of 0, 1, or 2), warfarin use was associated with a higher risk of stroke. There was no significant difference in stroke and bleeding outcomes among other ESRD patients with AF transitioned to dialysis regardless of CHA2DS2-VASC and HAS-BLED scores.