Abstract Number: PB2077
Meeting: ISTH 2020 Congress
Background: The benefit of anticoagulation in hemodialysis (HD) patients with atrial fibrillation (AF) is uncertain because of increased risk of both stroke and bleeding.
Aims: We aimed to evaluate anticoagulation in AF patients on HD.
Methods: In a prospective cohort of HD patients in Vienna, Austria, we selected patients with a diagnosis of AF at baseline or de-novo AF during follow-up (N=238, baseline characteristics given in table 1). During a maximum follow-up of 45 months, we recorded the occurrence of stroke, major bleeding, and for net-clinical benefit we analyzed a composite outcome of stroke, major bleeding and cardiovascular death. Exposure to anticoagulation included vitamin-K-antagonist (VKA) and long-term low-molecular-weight heparin (LMWH).
Risks for outcome occurrence for patients on anticoagulation were analyzed treating AF as a time-dependent variable and death as a competing event.
Results: During follow-up 25 (10.5%) patients suffered strokes, 42 (17.6%) patients had major bleeding, and 90 (39.4%) patients reached the net-clinical benefit endpoint. Anticoagulation was received by 99 patients (41.6%), including 61 (25.6%) patients on VKA and 38 (16.0%) on LMWH.
Treatment with anticoagulant agents did not result in a significantly reduced risk of stroke (subdistribution hazard ratio (SHR) 0.79, 95%CI 0.35-1.79, p=0.565), but a significantly increased risk of major bleeding after adjustment for prior stroke and antiplatelet co-medication (SHR 2.07, 95%CI 1.07-4.01, p=0.031) compared to no anticoagulation.
Patients on anticoagulation were further at significantly increased risk for occurrence of the net-clinical benefit outcome (SHR 1.55, 95%CI 1.03-2.34, p=0.037) which remained statistically significant after multivariable adjustment for prior stroke and antiplatelet comedication (SHR 1.71, 95%CI 1.09-2.70, p=0.020). Especially patients with antiplatelet comedication were at increased risk for the net-clinical benefit outcome (table 2).
Conclusions: In HD patients with AF treated with anticoagulant agents, we found increased risk of major bleeding and no reduced risk of stroke, resulting in no net-clinical benefit of anticoagulation.
|Characteristic||No anticoaguatlion N = 139 (58.4%)||With anticoagulation N = 99 (41.6%)||p-value|
|Female sex||50 (36.0%)||70 (70.7%)||0.329|
|Age, median (25th to 75th percentile)||73 (69 – 76)||71 (70 – 74)||0.594|
|CHA2DS2-Vasc Score, median (25th to 75th percentile)||4 (3 – 5)||4 (3 – 4)||0.546|
|Prior stroke||25 (18.0%)||38 (38.4%)||0.001|
|Cardiovascular disease||84 (60.4%)||65 (65.7%)||0.419|
|Congestive heart failure||49 (35.3%)||43 (43.3%)||0.225|
|Diabetes||63 (45.7%)||39 (39.4%)||0.355|
|Smokers||64 (46.7%)||50 (51.5%)||0.508|
|Antiplatelet comedication||98 (70.5%)||39 (39.4%)||<0.001|
[Table 1: Baseline patient characteristics according to anticoagulation treatment]
|Covariable||Subdistribution hazard ratio||95% CI||p-value|
|No antithrombotic treatment||1||–||–|
|LMWH mono-therapy||1.57||0.52 – 4.74||0.420|
|VKA mono-therapy||2.80||1.19 – 6.56||0.018|
|Antiplatelet mono-therapy||2.05||0.90 – 4.64||0.087|
|LMWH + antiplatelet therapy||3.03||1.15 – 7.94||0.025|
|VKA + antiplatelet therapy||2.94||1.05 – 8.26||0.041|
|History of stroke||1.16||0.73 – 1.86||0.524|
[Table 2: Multivariable subdistribution hazard model for net-clinical benefit]
To cite this abstract in AMA style:Königsbrügge O, Schmaldienst S, Auinger M, Lorenz M, Klauser-Braun R, Kletzmayr J, Pabinger I, Säemann M, Ay C. Stroke, Major Bleeding, and Net-clinical Benefit of Anticoagulation in Patients with Atrial Fibrillation on Hemodialysis [abstract]. Res Pract Thromb Haemost. 2020; 4 (Suppl 1). https://abstracts.isth.org/abstract/stroke-major-bleeding-and-net-clinical-benefit-of-anticoagulation-in-patients-with-atrial-fibrillation-on-hemodialysis/. Accessed November 30, 2021.
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