title: Risks of Death and Stroke in Patients Undergoing Hemodialysis With New-Onset Atrial Fibrillation: A Competing-Risk Analysis of a Nationwide Cohort.
abstract: BACKGROUND
  Whether oral anticoagulant use should be considered in patients undergoing hemodialysis with atrial fibrillation (AF) remains controversial because of the uncertainty regarding risk-benefit assessments. The purpose of this study was to investigate the risk of ischemic stroke in patients undergoing hemodialysis with new-onset AF, in comparison with those without arrhythmia.
  
  
  RESULTS
  This nationwide, population-based, propensity score-matched cohort study used data from Taiwan's National Health Insurance Research Database during 1998 to 2011 for patients on hemodialysis with new-onset nonvalvular AF and matched subjects without arrhythmia. The clinical end points were ischemic stroke (fatal or nonfatal), all-cause death, and other serious adverse cardiovascular events. In comparison with the matched cohort, patients with AF (n=6772) had higher risks of ischemic stroke (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [CI], 1.13-1.43), all-cause death (aHR, 1.59; 95% CI, 1.52-1.67), in-hospital cardiovascular death (aHR, 1.83; 95% CI, 1.71-1.94), myocardial infarction (aHR, 1.33; 95% CI, 1.17-1.51), and hospitalization for heart failure (aHR, 1.90; 95% CI, 1.76-2.05). After considering in-hospital death as a competing risk, AF significantly increased the risk of heart failure (HR, 1.56; 95% CI, 1.45-1.68), but not those of ischemic stroke and myocardial infarction. Additionally, the predictive value of the CHA2DS2-VASc score for ischemic stroke was diminished in the competing-risk model.
  
  
  CONCLUSIONS
  The risk of stroke was only modestly higher in patients undergoing hemodialysis with new-onset AF than in those without AF, and it became insignificant when accounting for the competing risk of in-hospital death.
authors.affiliation: From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.).
authors.forename: Chia-Jen
authors.initials: CJ
authors.lastname: Shih
authors.affiliation: From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.).
authors.forename: Shuo-Ming
authors.initials: SM
authors.lastname: Ou
authors.affiliation: From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.).
authors.forename: Pei-Wen
authors.initials: PW
authors.lastname: Chao
authors.affiliation: From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.).
authors.forename: Shu-Chen
authors.initials: SC
authors.lastname: Kuo
authors.affiliation: From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.).
authors.forename: Yi-Jung
authors.initials: YJ
authors.lastname: Lee
authors.affiliation: From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.).
authors.forename: Chih-Yu
authors.initials: CY
authors.lastname: Yang
authors.affiliation: From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.).
authors.forename: Der-Cherng
authors.initials: DC
authors.lastname: Tarng
authors.affiliation: From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.).
authors.forename: Chih-Ching
authors.initials: CC
authors.lastname: Lin
authors.affiliation: From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.).
authors.forename: Po-Hsun
authors.initials: PH
authors.lastname: Huang
authors.affiliation: From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.). ytchen0117@gmail.com syli@vghtpe.gov.tw.
authors.forename: Szu-Yuan
authors.initials: SY
authors.lastname: Li
authors.affiliation: From School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.S., S.-M.O., S.-C.K., Y.-J.L., C.-Y.Y., D.-C.T., C.-C.L., P.-H.H., S.-Y.L., Y.-T.C.); Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan (C.-J.S.); Deran Clinic, Yilan, Taiwan (C.-J.S.); Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (S.-M.O., C.-Y.Y., D.-C.T., C.-C.L., S.-Y.L.); Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan (S.-M.O., Y.-T.C.); Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan (P.-W.C.); School of Medicine, Taipei Medical University, Taipei, Taiwan (P.-W.C.); National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan (S.-C.K.); Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan (S.-C.K.); Department of Neurology, Taipei City Hospital, Ren Ai Branch, Taipei, Taiwan (Y.-J.L.); Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (P.-H.H.); and Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan (Y.-T.C.). ytchen0117@gmail.com syli@vghtpe.gov.tw.
authors.forename: Yung-Tai
authors.initials: YT
authors.lastname: Chen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance; D006435:Renal Dialysis / Q000401:mortality*; D012189:Retrospective Studies; D012307:Risk Factors; D013223:Statistics as Topic; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality*; D013624:Taiwan / Q000453:epidemiology
keywords: atrial fibrillation; death; dialysis; epidemiology; risk; stroke