Hemorrhagic Versus Ischemic Risk in Patients with Atrial Fibrillation on Hemodialysis

Abstract Background Hemodialysis (HD) patients with atrial fibrillation (AF) have a particularly high risk of stroke and bleeding, but no high-quality evidence-based recommendations exist to properly manage these patients. Objectives We aim to evaluate the ischemic versus the hemorrhagic risk in a HD population with AF. Methods We selected incident patients that started hemodialysis between 2011 and 2015. All patients that had AF before HD, or developed AF during the follow-up, were included. Both CHA2DS2 -VASC and HAS-BLED scores were calculated at the time of beginning of HD or AF diagnosis and correlated with the outcomes using a logistic regression model. The outcomes were hemorrhagic events, ischemic events and death related to any of these events. A p-value < 0.05 was set as statistically significant. Results Forty-six patients were included. Most of them had had AF before they started hemodialysis. Twenty-two patients were on oral anticoagulation (OAC). There was no significant difference between the incidence of ischemic and hemorrhagic events, regardless of the use of OAC. Previous stroke, transient ischemic attack, and thromboembolic event significantly increased the risk of an ischemic event (OR 6.78, p=0.028). Conclusions In this population, we did not observe any difference between the incidence of ischemic and hemorrhagic events, which was also true in patients with OAC. Therefore, the benefit of OAC in such patients remains questionable. However, patients with previous stroke, transient ischemic attack, or thromboembolic event seem to have a higher risk of new ischemic events and might benefit from anticoagulation.

摘要 背景：合并心房颤动（atrial fibrillation，AF）的血液透析（Hemodialysis，HD）患者发生卒中和出血的风险显著升高，但目前尚无高质量循证推荐方案用于该类患者的规范化管理。

目的：本研究旨在评估合并心房颤动的血液透析人群的缺血性事件与出血性事件风险。

方法：本研究纳入2011至2015年间开始接受血液透析的新发患者。所有在血液透析前已确诊心房颤动，或在随访期间新发心房颤动的患者均被纳入研究。在开始血液透析或确诊心房颤动时，分别计算患者的CHA₂DS₂-VASc评分与HAS-BLED评分，并通过logistic回归模型分析评分与结局事件的相关性。本研究的结局事件包括出血性事件、缺血性事件，以及上述事件相关死亡。本研究设定P值<0.05为具有统计学显著性。

结果：本研究共纳入46例患者，其中多数在开始血液透析前已存在心房颤动。22例患者接受了口服抗凝治疗（oral anticoagulation，OAC）。无论是否使用口服抗凝治疗，缺血性事件与出血性事件的发生率均无显著差异。既往卒中、短暂性脑缺血发作（transient ischemic attack）及血栓栓塞事件可显著升高缺血性事件发生风险（比值比（Odds Ratio，OR）=6.78，P=0.028）。

结论：在本研究纳入的人群中，缺血性事件与出血性事件的发生率无显著差异，在接受口服抗凝治疗的患者中同样如此。因此，口服抗凝治疗在该类患者中的获益仍不明确。不过，既往存在卒中、短暂性脑缺血发作或血栓栓塞事件的患者，新发缺血性事件的风险更高，或许可从抗凝治疗中获益。