Atrial fibrillation (AF) affects approximately 1 in every 4 patients with end-stage renal disease (ESRD). This population carries a high burden of comorbidities and an increased risk of cardiovascular events. Moreover, ESRD is a hypercoagulable state characterized by elevated coagulation factors and higher rates of ischemic events. Conversely, these patients also exhibit platelet dysfunction, which increases the risk of bleeding. This dual risk profile poses a clinical dilemma when optimizing stroke prevention strategies for this population.
Left atrial appendage (LAA) closure has emerged as a viable alternative to oral anticoagulation (OAC) in patients at high risk of bleeding. However, the role of LAA closure in patients with ESRD remains unclear, as this population was excluded from randomized clinical trials assessing its efficacy and safety.
The objective of this study was to evaluate the clinical outcomes of various stroke prevention strategies, including apixaban, warfarin, and LAA closure, in patients with ESRD.
The primary endpoint (PEP) was a composite of ischemic stroke, systemic embolism (SE), major bleeding, or death. The secondary endpoint (SEP) included the individual components of the PEP, as well as gastrointestinal bleeding and intracranial hemorrhage.
A total of 14,849 patients (42.9% women) were included, of whom 15.9% (n = 2,360), 27.4% (n = 4,077), and 56.7% (n = 8,412) received treatment with LAA closure, apixaban, and warfarin, respectively. After propensity score matching, 1,947 patients were analyzed in each group. The median follow-up was 0.9 years (Q1–Q3: 0.4–1.6 years).
The rate of the PEP was significantly higher in the warfarin group compared with the LAA closure group (HR: 1.26; 95% CI: 1.17–1.39; p < 0.001), as well as in the apixaban group compared with the LAA closure group (HR: 1.27; 95% CI: 1.16–1.39; p < 0.001). Rates of major bleeding, gastrointestinal bleeding, and stroke or systemic embolism were significantly higher in the apixaban and warfarin groups, while all-cause mortality and intracranial hemorrhage rates were similar between both groups.
Conclusion
In this study, LAA closure compared with oral anticoagulation in patients with AF and ESRD was associated with lower rates of the primary endpoint, mainly driven by a reduction in major bleeding, gastrointestinal bleeding, and possibly ischemic events. Left atrial appendage closure may represent a safe and effective option for patients with chronic kidney disease, atrial fibrillation, and high stroke risk.
Original Title: Outcomes of Stroke Prevention Strategies in Patients With Atrial Fibrillation and End-Stage Renal Disease.
Reference: Abdullah Al-Abcha, MD et al JACC Cardiovasc Interv. 2025.
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