Jonathan C. Hsu, MD, on Stroke Prevention in Patients With AFib and ESRD
Patients with end-stage renal disease (ESRD) and atrial fibrillation (AFib) tend to also have risk factors for stroke. Current treatment options for AFib may also increase the risk for bleeding events. Though few randomized controlled trials have examined effective treatment options that reduce the risk for bleeding in this patient population, non-vitamin K antagonist oral anticoagulants (NOACs) may be a potentially effective and safe option for these patients.
This was the topic of discussion during a session at the 40th Heart Rhythm Scientific Sessions, led by Jonathan C. Hsu, MD, who is an associate clinical professor of medicine and a cardiac electrophysiologist in the Division of Cardiology at the University of California San Diego School of Medicine.
Cardiology Consultant caught up with Dr Hsu after his session.1
CARDIOLOGY CONSULTANT: Your session was about stroke prevention in patients with AFib and renal disease. Can you tell us more about that discussion?
Jonathan Hsu: Patients with ESRD, AFib, and risk factors for stroke are a difficult patient population to manage. Several observational studies in the population show a signal for harm (ie, bleeding) using treatment with coumadin and potential for no benefit with stroke risk reduction.
The NOACs are an intriguing option in this patient population, but there are limited studies, and many have some level of renal excretion, causing us to question their use in this population. There have been no randomized controlled trials of left atrial appendage occlusion in patients with ESRD, and experience has been limited but shows promise.
CARDIO CON: Can you give us an example of a challenging patient to illustrate how to decide which treatment regimen to prescribe when?
JH: We took care of a patient with ESRD and AFib who was started on coumadin. The patient had gastrointenstinal bleeding, and anticoagulation was stopped. A WATCHMAN left atrial appendage occlusion device was sought, and the patient was prescribed apixaban for 45 days after the procedure. So far, the patient has been doing well.
CARDIO CON: What other knowledge gaps might still exist in this area of medicine?
JH: More randomized controlled data regarding NOACs and left atrial appendage occlusion devices in patients with end-stage renal disease and atrial fibrillation are needed.
CARDIO CON: What is the key take-home message for cardiologists?
JH: This is a difficult patient population to manage with limited data. In patients with end-stage renal disease, atrial fibrillation, and risk factors for stroke, existing data must be considered in the context of risks and patient wishes.
Hsu JC. Stroke prevention in AF patients with renal disease: coumadin, NOACs, or LAA occlusion. Presented at: 40th Heart Rhythm Scientific Sessions; May 8-11, 2019; San Francisco, CA. https://www.abstractsonline.com/pp8/#!/5753/presentation/24873. Accessed May 21, 2019.