Risks of Death and Stroke in Patients Undergoing Hemodialysis With New-Onset Atrial Fibrillation A Competing-Risk Analysis of a Nationwide Cohort

Background —Whether oral anticoagulant (OAC) use should be considered in patients undergoing hemodialysis with atrial fibrillation (AF) remains controversial due to uncertainty regarding risk-benefit assessments. The purpose of this study was to investigate the risk of ischemic stroke in patients undergoing hemodialysis with new-onset AF, compared with those without arrhythmia. Methods and Results —This nationwide, population-based, propensity score-matched cohort study used data from Taiwan9s National Health Insurance Research Database during 1998-2011 for patients on hemodialysis with new-onset non-valvular AF and matched subjects without arrhythmia. The clinical endpoints were ischemic stroke (fatal or non-fatal), all-cause death, and other serious adverse cardiovascular events. Compared with the matched cohort, patients with AF (n = 6,772) had higher risks of ischemic stroke (adjusted hazard ratio [aHR] 1.27, 95% confidence interval [CI] 1.13-1.43), all-cause death (aHR 1.59, 95% CI 1.52-1.67), in-hospital cardiovascular death (aHR 1.83, 95% CI 1.71-1.94), myocardial infarction (aHR 1.33, 95% CI 1.17-1.51), and hospitalization for heart failure (aHR 1.90, 95% CI 1.76-2.05). After considering in-hospital death as a competing risk, AF significantly increased the risk of heart failure (HR 1.56, 95% CI 1.45-1.68), but not those of ischemic stroke and myocardial infarction. Additionally, the predictive value of the CHA 2 DS 2 -VASc score for ischemic stroke was diminished in the competing risk model. Conclusions —The risk of stroke was only modestly higher in patients undergoing hemodialysis with new-onset AF than in those without AF, and it became insignificant when accounting for the competing risk of in-hospital death.