Patients with ESRD and AF face a challenging balance between preventing stroke and avoiding bleeding complications. A large national registry analysis, published in JACC: Cardiovascular Interventions, compared outcomes among those treated with LAAO, apixaban, or warfarin.

Among 14,849 patients (43% women), 15.9% underwent LAAO, 27.4% received apixaban, and 56.7% received warfarin. After propensity score matching, 1,947 patients were analyzed in each group over a median follow-up of 0.9 years.

The composite endpoint, which included ischemic stroke or systemic embolism, major bleeding, and death, occurred significantly less often after LAAO than with either anticoagulant. Compared with LAAO, the adjusted hazard ratio was 1.26 (95% CI: 1.17 to 1.39; P < 0.001) for warfarin and 1.27 (95% CI: 1.16 to 1.39; P < 0.001) for apixaban. Gastrointestinal and major bleeding events were more frequent with drug therapy, whereas rates of intracranial hemorrhage and all-cause mortality were similar across groups.

These findings show that LAAO is a safer and more effective option for stroke prevention in patients with ESRD and atrial fibrillation. The benefit is most evident in those with high bleeding risk, where the use of anticoagulant therapy is limited.