Stroke Prevention in Patients With Atrial Fibrillation Receiving Dialysis: A Systematic Review
Authors: Massé Olivier , Dallaire Gabriel , Maurice Noémie , Hong Yu , Mercurio Claudia Mei , Tremblay Catherine , Dugré Nicolas , Bernier-Jean Amélie 
Published: February 2025

Background: Despite atrial fibrillation affecting nearly 25% of patients receiving dialysis, conflicting study findings and guideline recommendations continue to make individual treatment decisions challenging. Objective: The objective was to examine the efficacy and safety of stroke-prevention interventions in patients with atrial fibrillation receiving dialysis. Design: A systematic review of randomized controlled trials and observational studies. Patients: Adult patients with non-valvular atrial fibrillation receiving any type of dialysis. Measurements: Ischemic strokes or systemic embolism, major bleeding, and all-cause mortality. Methods: We searched Medline, Embase, Cochrane Central Register of Controlled Trials, and the gray literature from inception to February 16, 2023. We selected all studies comparing antiplatelet, anticoagulant agents or left atrial appendage closure to placebo, no treatment, or an active comparator (most often vitamin K antagonists). Two reviewers independently screened and included the studies, extracted the data and assessed the risk of bias using the Cochrane Risk of Bias tool (version 1) and the Newcastle-Ottawa Scale. When randomized controlled trials were available, we pooled the risk ratios using fixed-effect meta-analyses. Results from observational studies were described narratively. We appraised the certainty of evidence (CoE) of the findings using GRADE. Results: Of the 8526 citations identified, we included 50 studies (4 randomized controlled trials and 46 observational studies) involving 155 058 participants. Our meta-analysis of 4 randomized controlled trials of direct oral anticoagulants (apixaban or rivaroxaban) compared with vitamin K antagonists (486 participants) suggested that the effect of direct oral anticoagulants on ischemic strokes or systemic embolism is very uncertain (risk ratio [RR] = 0.52; 95% confidence interval [CI] = 0.22-1.20; very low CoE). Direct oral anticoagulants may decrease major bleeding (RR = 0.67; 95% CI = 0.44-1.03; low CoE) and may result in little to no difference in mortality (RR = 0.89; 95% CI = 0.70-1.13; low CoE). Our narrative review of the observational evidence suggests that, compared with no treatment, vitamin K antagonists may decrease ischemic strokes or systemic embolism (18 studies, low CoE) and likely increase major bleeding (12 studies, moderate CoE), whereas their effect on mortality is very uncertain (16 studies, very low CoE). Compared with no treatment, the effect of direct oral anticoagulants on all outcomes is very uncertain (2 studies, very low CoE). We also found that the effect of antiplatelet agents, left atrial appendage closure, and heparin-related therapies is very uncertain on all outcomes (very low CoE), except for antiplatelet agents that may increase major bleeding (1 study, low CoE) compared with no treatment. Limitations: Most of the included studies were observational and retrospective, resulting in low or very low certainty for nearly all of the outcomes. The included interventions were highly heterogeneous, which precluded meta-analysis of the results in all cases except for direct oral anticoagulants. Conclusion: In patients with atrial fibrillation receiving dialysis, vitamin K antagonists may decrease ischemic strokes or systemic embolism compared with no treatment at the cost of an increased risk of major bleeding. Direct oral anticoagulants (apixaban or rivaroxaban) may also lead to less major bleeding than vitamin K antagonists. The overall low to very low certainty of the evidence emphasizes the importance of engaging in shared decision-making when selecting a strategy for stroke prevention for atrial fibrillation in people receiving maintenance dialysis. PROSPERO registration ID: CRD42022307009.