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Commentary |

The Intersection of Risk and Benefit: Is Warfarin Anticoagulation Suitable for Atrial Fibrillation in Patients on Hemodialysis?

Manish M. Sood, MD; Paul Komenda, MD, MHA, CHE; Amy R. Sood, PharmD; Claudio Rigatto, MD, MSc; Joe Bueti, MD
Author and Funding Information

Affiliations: From the Department of Medicine (Drs. M. Sood, Komenda, Rigatto, and Bueti), Department of Pharmacy (Dr. A. Sood), Health Sciences Centre (Dr. Bueti), and St. Boniface General Hospital (Drs. M. Sood, A. Sood, Rigatto, and Komenda), Winnipeg, MB, Canada.

Correspondence to: Manish M. Sood, MD, BG 007, 409 Tache Ave, St. Boniface General Hospital, Winnipeg, MB, R3X 2A6, Canada; e-mail: msood@sbgh.mb.ca


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(4):1128-1133. doi:10.1378/chest.09-0730
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The risks and benefits of anticoagulation for stroke prevention with atrial fibrillation is clearly delineated in the general population. Little evidence exists for patients with end-stage renal disease (ESRD) about whether the extrapolation of these guidelines is appropriate. In patients with ESRD who are undergoing hemodialysis, the rates for both stroke and bleeding are 3 to 10 times higher than that for the general population. Furthermore, the proportion of hemorrhagic to ischemic strokes has increased, making the decision of whether to initiate anticoagulation problematic. In this commentary, we discuss the existing literature for stroke in atrial fibrillation, stroke type, risk reduction with anticoagulation, and bleeding risks in the hemodialysis population. We comment on validated risk stratification models of stroke prevention and bleeding and their applicability to patients undergoing hemodialysis. Finally, we recommend treatment strategies that are based on the existing state of knowledge.


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