Does it mean that OACs should not be used for stroke prevention in AF in individuals with CKD? Although robust evidence from randomized trials is lacking in this regard, observational data from health-care systems with efficient INR control do support OAC utilization. A large retrospective study from Sweden covering more than 13,000 patients with AF and CKD showed significant benefits of warfarin despite a higher bleeding risk, and the net benefit was lower than expected in patients with normal renal function. Despite a higher propensity for bleeding reflected by a hypertension, abnormal renal function, stroke, bleeding, labile INRs, elderly, drug therapy score of > 3, patients with renal failure still had a statistically significant reduction in ischemic stroke or death when warfarin was used. Of note, well-managed warfarin was associated with a low risk of intracranial bleeding, the most feared complication of OAC.