Warfarin Use in Patients with Atrial Fibrillation Undergoing Hemodialysis: A Nationwide Population-Based Study

Chang Yun Yoon; Juhwan Noh; Jong Hyun Jhee; Tae Ik Chang; Ea Wha Kang; Youn Kyung Kee; Hyoungnae Kim; Seohyun Park; Hae Ryong Yun; Su Young Jung; Hyung Jung Oh; Jung Tak Park; Seung Hyeok Han; Shin Wook Kang; Changsoo Kim; Tae Hyun Yoo

doi:10.1161/STROKEAHA.117.017114

Warfarin Use in Patients with Atrial Fibrillation Undergoing Hemodialysis: A Nationwide Population-Based Study

Chang Yun Yoon, Juhwan Noh, Jong Hyun Jhee, Tae Ik Chang, Ea Wha Kang, Youn Kyung Kee, Hyoungnae Kim, Seohyun Park, Hae Ryong Yun, Su Young Jung, Hyung Jung Oh, Jung Tak Park, Seung Hyeok Han, Shin Wook Kang, Changsoo Kim, Tae Hyun Yoo

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Abstract

Background and Purpose - The aim of this study is to elucidate the effects of warfarin use in patients with atrial fibrillation undergoing dialysis using a population-based Korean registry. Methods - Data were extracted from the Health Insurance Review and Assessment Service, which is a nationwide, mandatory social insurance database of all Korean citizens enrolled in the National Health Information Service between 2009 and 2013. Thromboembolic and hemorrhagic outcomes were analyzed according to warfarin use. Overall and propensity score-matched cohorts were analyzed by Cox proportional hazards models. Results - Among 9974 hemodialysis patients with atrial fibrillation, the mean age was 66.6±12.2 years, 5806 (58.2%) were men, and 2921 (29.3%) used warfarin. After propensity score matching to adjust for all described baseline differences, 5548 subjects remained, and differences in baseline variables were distributed equally between warfarin users and nonusers. During a mean follow-up duration of 15.9±11.1 months, ischemic and hemorrhagic stroke occurred in 678 (6.8%) and 227 (2.3%) patients, respectively. In a multiple Cox model, warfarin use was significantly associated with an increased risk of hemorrhagic stroke (hazard ratio, 1.44; 95% confidence interval, 1.09-1.91; P=0.010) in the overall cohort. Furthermore, a significant relationship between warfarin use and hemorrhagic stroke was found in propensity-matched subjects (hazard ratio, 1.56; 95% confidence interval, 1.10-2.22; P=0.013). However, the ratios for ischemic stroke were not significantly different in either the propensity-matched (hazard ratio, 0.95; 95% confidence interval, 0.78-1.15; P=0.569) or overall cohort (hazard ratio, 1.06; 95% confidence interval, 0.90-1.26; P=0.470). Conclusions - Our findings suggest that warfarin should be used carefully in hemodialysis patients, given the higher risk of hemorrhagic events and the lack of ability to prevent thromboembolic complications.

Original language	English
Pages (from-to)	2472-2479
Number of pages	8
Journal	Stroke
Volume	48
Issue number	9
DOIs	https://doi.org/10.1161/STROKEAHA.117.017114
Publication status	Published - 2017 Sept 1

Bibliographical note

Funding Information:
This work was supported by the Brain Korea 21 Project for Medical Science, Yonsei University, through a National Research Foundation of Korea (NRF) grant funded by the Korean government (MEST) (NRF-2014R1A2A1A11050098 & NRF-2017R1A2B4005720), by a grant from the Korea Healthcare Technology R&D Project, Ministry of Health and Welfare, Republic of Korea (H14C2003), and by the Handok Incorporation.

Publisher Copyright:
© 2017 American Heart Association, Inc.

All Science Journal Classification (ASJC) codes

Clinical Neurology
Cardiology and Cardiovascular Medicine
Advanced and Specialised Nursing

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10.1161/STROKEAHA.117.017114

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Yoon, C. Y., Noh, J., Jhee, J. H., Chang, T. I., Kang, E. W., Kee, Y. K., Kim, H., Park, S., Yun, H. R., Jung, S. Y., Oh, H. J., Park, J. T., Han, S. H., Kang, S. W., Kim, C., & Yoo, T. H. (2017). Warfarin Use in Patients with Atrial Fibrillation Undergoing Hemodialysis: A Nationwide Population-Based Study. Stroke, 48(9), 2472-2479. https://doi.org/10.1161/STROKEAHA.117.017114

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title = "Warfarin Use in Patients with Atrial Fibrillation Undergoing Hemodialysis: A Nationwide Population-Based Study",

abstract = "Background and Purpose - The aim of this study is to elucidate the effects of warfarin use in patients with atrial fibrillation undergoing dialysis using a population-based Korean registry. Methods - Data were extracted from the Health Insurance Review and Assessment Service, which is a nationwide, mandatory social insurance database of all Korean citizens enrolled in the National Health Information Service between 2009 and 2013. Thromboembolic and hemorrhagic outcomes were analyzed according to warfarin use. Overall and propensity score-matched cohorts were analyzed by Cox proportional hazards models. Results - Among 9974 hemodialysis patients with atrial fibrillation, the mean age was 66.6±12.2 years, 5806 (58.2%) were men, and 2921 (29.3%) used warfarin. After propensity score matching to adjust for all described baseline differences, 5548 subjects remained, and differences in baseline variables were distributed equally between warfarin users and nonusers. During a mean follow-up duration of 15.9±11.1 months, ischemic and hemorrhagic stroke occurred in 678 (6.8%) and 227 (2.3%) patients, respectively. In a multiple Cox model, warfarin use was significantly associated with an increased risk of hemorrhagic stroke (hazard ratio, 1.44; 95% confidence interval, 1.09-1.91; P=0.010) in the overall cohort. Furthermore, a significant relationship between warfarin use and hemorrhagic stroke was found in propensity-matched subjects (hazard ratio, 1.56; 95% confidence interval, 1.10-2.22; P=0.013). However, the ratios for ischemic stroke were not significantly different in either the propensity-matched (hazard ratio, 0.95; 95% confidence interval, 0.78-1.15; P=0.569) or overall cohort (hazard ratio, 1.06; 95% confidence interval, 0.90-1.26; P=0.470). Conclusions - Our findings suggest that warfarin should be used carefully in hemodialysis patients, given the higher risk of hemorrhagic events and the lack of ability to prevent thromboembolic complications.",

author = "Yoon, {Chang Yun} and Juhwan Noh and Jhee, {Jong Hyun} and Chang, {Tae Ik} and Kang, {Ea Wha} and Kee, {Youn Kyung} and Hyoungnae Kim and Seohyun Park and Yun, {Hae Ryong} and Jung, {Su Young} and Oh, {Hyung Jung} and Park, {Jung Tak} and Han, {Seung Hyeok} and Kang, {Shin Wook} and Changsoo Kim and Yoo, {Tae Hyun}",

note = "Funding Information: This work was supported by the Brain Korea 21 Project for Medical Science, Yonsei University, through a National Research Foundation of Korea (NRF) grant funded by the Korean government (MEST) (NRF-2014R1A2A1A11050098 & NRF-2017R1A2B4005720), by a grant from the Korea Healthcare Technology R&D Project, Ministry of Health and Welfare, Republic of Korea (H14C2003), and by the Handok Incorporation. Publisher Copyright: {\textcopyright} 2017 American Heart Association, Inc.",

year = "2017",

month = sep,

day = "1",

doi = "10.1161/STROKEAHA.117.017114",

language = "English",

volume = "48",

pages = "2472--2479",

journal = "Stroke",

issn = "0039-2499",

publisher = "Lippincott Williams and Wilkins",

number = "9",

}

TY - JOUR

T1 - Warfarin Use in Patients with Atrial Fibrillation Undergoing Hemodialysis

T2 - A Nationwide Population-Based Study

AU - Yoon, Chang Yun

AU - Noh, Juhwan

AU - Jhee, Jong Hyun

AU - Chang, Tae Ik

AU - Kang, Ea Wha

AU - Kee, Youn Kyung

AU - Kim, Hyoungnae

AU - Park, Seohyun

AU - Yun, Hae Ryong

AU - Jung, Su Young

AU - Oh, Hyung Jung

AU - Park, Jung Tak

AU - Han, Seung Hyeok

AU - Kang, Shin Wook

AU - Kim, Changsoo

AU - Yoo, Tae Hyun

N1 - Funding Information: This work was supported by the Brain Korea 21 Project for Medical Science, Yonsei University, through a National Research Foundation of Korea (NRF) grant funded by the Korean government (MEST) (NRF-2014R1A2A1A11050098 & NRF-2017R1A2B4005720), by a grant from the Korea Healthcare Technology R&D Project, Ministry of Health and Welfare, Republic of Korea (H14C2003), and by the Handok Incorporation. Publisher Copyright: © 2017 American Heart Association, Inc.

PY - 2017/9/1

Y1 - 2017/9/1

N2 - Background and Purpose - The aim of this study is to elucidate the effects of warfarin use in patients with atrial fibrillation undergoing dialysis using a population-based Korean registry. Methods - Data were extracted from the Health Insurance Review and Assessment Service, which is a nationwide, mandatory social insurance database of all Korean citizens enrolled in the National Health Information Service between 2009 and 2013. Thromboembolic and hemorrhagic outcomes were analyzed according to warfarin use. Overall and propensity score-matched cohorts were analyzed by Cox proportional hazards models. Results - Among 9974 hemodialysis patients with atrial fibrillation, the mean age was 66.6±12.2 years, 5806 (58.2%) were men, and 2921 (29.3%) used warfarin. After propensity score matching to adjust for all described baseline differences, 5548 subjects remained, and differences in baseline variables were distributed equally between warfarin users and nonusers. During a mean follow-up duration of 15.9±11.1 months, ischemic and hemorrhagic stroke occurred in 678 (6.8%) and 227 (2.3%) patients, respectively. In a multiple Cox model, warfarin use was significantly associated with an increased risk of hemorrhagic stroke (hazard ratio, 1.44; 95% confidence interval, 1.09-1.91; P=0.010) in the overall cohort. Furthermore, a significant relationship between warfarin use and hemorrhagic stroke was found in propensity-matched subjects (hazard ratio, 1.56; 95% confidence interval, 1.10-2.22; P=0.013). However, the ratios for ischemic stroke were not significantly different in either the propensity-matched (hazard ratio, 0.95; 95% confidence interval, 0.78-1.15; P=0.569) or overall cohort (hazard ratio, 1.06; 95% confidence interval, 0.90-1.26; P=0.470). Conclusions - Our findings suggest that warfarin should be used carefully in hemodialysis patients, given the higher risk of hemorrhagic events and the lack of ability to prevent thromboembolic complications.

AB - Background and Purpose - The aim of this study is to elucidate the effects of warfarin use in patients with atrial fibrillation undergoing dialysis using a population-based Korean registry. Methods - Data were extracted from the Health Insurance Review and Assessment Service, which is a nationwide, mandatory social insurance database of all Korean citizens enrolled in the National Health Information Service between 2009 and 2013. Thromboembolic and hemorrhagic outcomes were analyzed according to warfarin use. Overall and propensity score-matched cohorts were analyzed by Cox proportional hazards models. Results - Among 9974 hemodialysis patients with atrial fibrillation, the mean age was 66.6±12.2 years, 5806 (58.2%) were men, and 2921 (29.3%) used warfarin. After propensity score matching to adjust for all described baseline differences, 5548 subjects remained, and differences in baseline variables were distributed equally between warfarin users and nonusers. During a mean follow-up duration of 15.9±11.1 months, ischemic and hemorrhagic stroke occurred in 678 (6.8%) and 227 (2.3%) patients, respectively. In a multiple Cox model, warfarin use was significantly associated with an increased risk of hemorrhagic stroke (hazard ratio, 1.44; 95% confidence interval, 1.09-1.91; P=0.010) in the overall cohort. Furthermore, a significant relationship between warfarin use and hemorrhagic stroke was found in propensity-matched subjects (hazard ratio, 1.56; 95% confidence interval, 1.10-2.22; P=0.013). However, the ratios for ischemic stroke were not significantly different in either the propensity-matched (hazard ratio, 0.95; 95% confidence interval, 0.78-1.15; P=0.569) or overall cohort (hazard ratio, 1.06; 95% confidence interval, 0.90-1.26; P=0.470). Conclusions - Our findings suggest that warfarin should be used carefully in hemodialysis patients, given the higher risk of hemorrhagic events and the lack of ability to prevent thromboembolic complications.

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Warfarin Use in Patients with Atrial Fibrillation Undergoing Hemodialysis: A Nationwide Population-Based Study

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