Oral anticoagulation and left atrial appendage closure in dialysis atrial fibrillation: between stroke prevention and bleeding hazard

Abstract

Atrial fibrillation (AF) is frequent in dialysis patients and associates with a substantial increase in stroke, cardiovascular events, and mortality, yet the net clinical benefit of oral anticoagulation (OAC) in this setting remains uncertain. Dialysis patients were excluded from pivotal vitamin K antagonists (VKAs) and direct anticoagulants (DOACs) trials, and observational data are conflicting. The PRO position argues that in carefully selected patients with very high thromboembolic risk and acceptable bleeding risk, thromboembolic prophylaxis—pharmacological with OAC or non-pharmacological with left atrial appendage closure (LAAC)—can reduce stroke and possibly mortality. This view is supported by several cohort studies suggesting lower ischemic events and improved survival when OAC is maintained, and international normalized ratio control is good, and by emerging data that LAAC may offer similar stroke protection with less bleeding and lower mortality than OAC or no prophylaxis. The CON position stresses that many large studies show no clear stroke reduction and consistently higher major bleeding with warfarin versus no OAC, that small randomized controlled trials of DOACs versus VKAs reveal very high absolute bleeding without clear efficacy gains, and that VKAs may aggravate vascular calcification. Both positions agree on the need for individualized, shared decision-making and for adequately powered randomized trials comparing OAC and LAAC with no specific therapy in dialysis AF.