Optimal Thromboembolism Prevention for Patients With Atrial Fibrillation on Long-Term Dialysis.

Background: Optimal strategies for thromboembolism prevention, including vitamin K antagonists (VKA), direct oral anticoagulants (DOAC), and left atrial appendage occlusion (LAAO), for patients with atrial fibrillation (AF) and on dialysis have not been fully investigated. We aimed to investigate the efficacy and safety of thromboembolism prevention strategies in AF patients on dialysis through a network meta-analysis.

Methods: Multiple databases were searched through January 2024. The primary efficacy endpoint was thrombotic events, defined as ischemic stroke or systemic thromboembolism, whereas the primary safety endpoint was major bleeding. These strategies were ranked using P-scores.

Results: Our study identified 28 eligible studies (including 3 randomized controlled trials) that enrolled 144,630 AF patients on dialysis. The risks of thrombotic events in any DOAC and VKA were comparable to no-anticoagulant, whereas LAAO was associated with a lower risk of thrombotic events (HR [95% CI]: 0.19 [0.06-0.60]). Compared to no-anticoagulant, VKA, regular-dose rivaroxaban, and dabigatran were associated with a higher risk of major bleeding, but rivaroxaban 10 mg daily, and apixaban 2.5 or 5 mg twice daily were not. LAAO, rivaroxaban 10 mg daily and apixaban 2.5 or 5 mg twice daily were highly ranked in efficacy and safety outcomes.

Conclusions: LAAO may possibly be the reasonable therapeutic option for AF patients on dialysis, but rivaroxaban 10 mg daily and apixaban 2.5 or 5 mg twice daily can also be considered. Further studies are warranted to confirm these findings.