A trial fibrillation (AF) is an increasingly prevalent heart rhythm disorder 1-3 for patients with end-stage renal disease (ESRD) who are undergoing hemodialysis and is associated with adverse outcomes and death in these patients. [4] [5] [6] Given the routine administration of heparin during hemodialysis and the bleeding tendency associated with ESRD, reports about whether the risk of thromboembolic stroke is notably higher in patients undergoing dialysis with AF than in those without AF

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... inconsistent. 7-9 Editorial see p 242 Clinical Perspective on p 272 Current American College of Cardiology/American Heart Association AF guidelines 10 do not provide strong recommendations for patients with nonvalvular AF undergoing dialysis; they suggest only the consideration of warfarin prescription for those with higher stroke risk (CHA 2 DS 2 -VASc≥2), based on limited findings from observational studies. 11 However, recent large-scale registry studies 12-16 involving patients with AF undergoing dialysis found that warfarin use was insignificantly or positively associated with ischemic stroke, major bleeding events, and mortality. These controversial findings have raised concern about the actual clinical impact of Background-Whether oral anticoagulant use should be considered in patients undergoing hemodialysis with atrial fibrillation (AF) remains controversial because of the 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, in comparison with those without arrhythmia. Methods and Results-This nationwide, population-based, propensity score-matched cohort study used data from Taiwan's National Health Insurance Research Database during 1998 to 2011 for patients on hemodialysis with new-onset nonvalvular AF and matched subjects without arrhythmia. The clinical end points were ischemic stroke (fatal or nonfatal), all-cause death, and other serious adverse cardiovascular events. In comparison with the matched cohort, patients with AF (n=6772) 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.