**1. Introduction**

Atrial fibrillation (AF) is the most common cardiac arrhythmia that can lead to thrombus formation in the atria and atrial appendages. It also causes reduction in cardiac output and affected individuals are at increased risk of mortality. The prevalence of AF in patients with end-stage kidney disease (ESKD) is higher than in general population.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Patients with AF are managed with antiarrhythmic agents to control their heart rate and with anticoagulant agents to prevent thromboembolic events. The benefits of anticoagulation in patients with AF (without kidney disease) are well established; however, the benefits and safety of anticoagulation in patients with AF and ESKD are still not clear.

**3. Goals of therapy for AF**

gender and age more than 75 years [9].

**4. Evaluation of embolic risk**

The mechanisms initiating and maintaining AF may be multifactorial in individual patients, including electrophysiological and structural abnormalities. The primary goals of therapy for AF are to control symptomatic effects of the disease and to prevent any disease-related complications such as thromboembolism and tachycardia-induced cardiomyopathy [9]. The management of AF therefore revolves around strategies for rate control, rhythm control and prevention of thromboembolic strokes. In relation to the former two strategies, multiple international guidelines, including the American College of Cardiology (ACC), the American Heart Association (AHA), European Society of Cardiology (ESC) and the Heart Rhythm Society (HRS) recommend that patients with no structural heart disease should be initiated with dofetilide, dronedarone, flecainide, propafenone, or sotalol, as these agents are found to have the lowest level of cardiac toxicity [9]. If first line therapy is contraindicated or shown to be ineffective, second-line therapy is considered and includes either amiodarone or catheterdirected ablation [9]. Interestingly, amiodarone is considered as first line therapy in patients with substantial left ventricular (LV) hypertrophy as these patients are seen to be at increased

Anticoagulation for Atrial Fibrillation in Patients with End-Stage Kidney Disease

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The prevention of thromboembolism including stroke prevention has been widely proven with the use of anticoagulants such as warfarin and DOACs. Stroke is seen to be the most common clinical thromboembolic event in patients with AF, with AF attributing to 36% of all strokes in individuals aged 80–89 years [10]. Furthermore, stroke occurring in patients who have AF tend to have a higher degree of severity as compared to those without AF [11]. Clinical markers predicting increased risk of stroke in patients with AF include previous history of transient ischemic attacks (TIA) or prior strokes, coronary artery disease, mitral stenosis, left ventricular dysfunction, heart failure (HF), hypertension, diabetes mellitus, female

Thrombus formation within the left atrial appendage occurs secondary to reduced blood flow velocities due to the loss of organized mechanical contraction in this anatomical area [12, 13]. Along with reduced flow velocity, other factors have also been attributed to the enhanced thrombogenicity in patients with AF. This includes reduced nitric oxide (NO) production in the left atrial endocardium, increased levels of the prothrombotic protein plasminogen activator inhibitor 1 (PAI-1), as well as elevated levels of β-thromboglobulin and platelet factor 4,

All individuals who have AF are not at equally high risk for thromboembolic events, and several predisposing clinical factors can identify those patients at relatively higher or lower risk. Risk stratification for embolic events assumes added importance, since the individual's risk of embolic events needs to be carefully balanced against the risk of bleeding which is associated with anticoagulation. In patients without CKD, AF in association with any form of valvular heart disease (VHD) is considered for anticoagulation commencement as the stroke risk in this population subset is high [3, 15, 16]. Patients with nonvalvular heart disease (NVHD),

von Willebrand factor (vWF), soluble thrombomodulin and fibrinogen [14].

proarrhythmic risk with most other first line antiarrhythmic drugs.

In this chapter, we discuss the prevalence of AF in ESKD and management of AF in these patients focusing on anticoagulation including the direct oral anticoagulants (DOACs).
