Anticoagulants in patients with atrial fibrillation and end-stage renal disease.

Atrial fibrillation (AF) is a common cardiac arrhythmia and is associated with an increased risk for thromboembolic stroke. Anticoagulant therapy has been shown to reduce the risk for ischemic stroke in patients with AF; however, these studies have excluded patients with end-stage renal disease (ESRD). This review examines the relationships between ESRD, AF, and the use of anticoagulants to prevent ischemic stroke. Medline and Embase were used to identify relevant articles. Identified review articles and their references were searched. The prevalence of AF in patients with ESRD is higher than that in the general population; ESRD appears to be an independent risk factor for AF. The presence of AF in patients with ESRD increases the risk for stroke, although this effect is less pronounced when compared with the general population. The presence of ESRD confers an increased risk for bleeding; warfarin appears to enhance this risk. Observational data suggest that warfarin increases the rate of hemorrhagic stroke in patients with ESRD, but are unclear on its utility in reducing ischemic stroke. In addition to increasing the risk for bleeding, warfarin may also promote vascular calcification in this population. Currently, there are no oral anticoagulants other than warfarin that are approved for use in patients with ESRD. Recent guidelines suggest that warfarin only be used for secondary prevention in patients with ESRD and AF. Randomized controlled trials are needed to clarify the role of warfarin or other anticoagulants in preventing stroke in patients with ESRD and AF.