J HONG1, M DAMASIEWICZ2,3, P KERR2,3
1Monash Health, Melbourne, Australia, 2Department of Nephrology, Monash Health, Melbourne, Australia, 3Department of Medicine, Monash University, Melbourne, Australia
Aim: To examine prescriber characteristics and reasoning for selection of stroke prevention therapy for dialysis patients with atrial fibrillation (AF).
Background: Warfarin therapy in dialysis patients with AF remains controversial especially for primary stoke prevention.
Methods: Utilising scanned medical records, dialysis patients with AF at Monash Health were identified. Patient demographics, therapeutic agent for AF, prescriber characteristics and reasoning were then assessed.
Results: Of 575 dialysis patients, 100 (17.4%) were identified as having AF. Of those, 31 patients received warfarin, 46 received antiplatelet therapy, 21 did not receive stroke prevention therapy and 2 received other forms of stroke prevention therapy (clexane non-dialysis days, apixaban). Of the 31 patients on warfarin, 15 were placed on warfarin for primary prevention, 13 for secondary prevention and 3 were unknown. The AF cohort was generally older compared to the cohort without AF (71.9 vs 61.2 years, p<0.001). Demographically, patient subgroups on warfarin, antiplatelet agents and no stroke prevention therapy were similar. 16 of 31 patients were commenced on warfarin by cardiology, predominantly for primary stroke prevention (81%). Neurology commenced warfarin in 9 of 31 patients, in all instances for secondary stroke prevention (100%). 16 patients were previously on warfarin. Most cases of warfarin cessation were instigated by nephrology (63%) with major reasons including conflicting evidence regarding warfarin use in dialysis patients, bleeding complications, bleed risk greater than stroke risk, and dialysis commencement.
Conclusions: Further research is required to provide an evidence-based approach to primary stroke prevention therapy in dialysis patients with AF. Presently, with limited evidence and differences in clinical practice between the various specialties, a multidisciplinary approach is necessary for the individualised management of AF in dialysis patients.
Joy Hong is a current intern at Monash Health with an interest in pursuing nephrology in the future