Association of Rate-Control and Antiarrhythmic Medication Use and Risk of Ischemic Stroke and Death in Patients on...

Incident atrial fibrillation (AF) is common among adults with kidney failure treated with maintenance dialysis and is associated with poor clinical outcomes. Limited data exist informing treatment of AF among patients on dialysis. We aimed to describe the use of rate-control and antiarrhythmic medications for AF among patients on dialysis and associations of these medication use strategies with stroke and all-cause death.

We evaluated patients on dialysis with incident AF between 2010 and 2017 in the Kaiser Permanente Northern and Southern California integrated health care delivery systems. We characterized time-updated incident receipt of rate-control (β blockers, calcium channel blockers, and digoxin) and antiarrhythmic medications from pharmacy databases. We evaluated associations of these therapies with the composite outcome of ischemic stroke and all-cause death using Cox regression, adjusting for potential confounders.

Of 2100 patients, 44.0% were newly prescribed rate-control medications, 4.6% were prescribed antiarrhythmic medications, 8.9% were prescribed both, and 42.9% were prescribed neither within 12 months of newly diagnosed AF. During a median 1.66 (interquartile range, 0.45-3.39) years, we observed 1406 composite events (stroke and death). Time-updated use of antiarrhythmics alone (adjusted hazard ratio [HR], 0.74 [95% CI, 0.57-0.96]) or with rate-control (adjusted HR, 0.72 [95% CI, 0.58-0.90]) was associated with lower stroke or death risk versus neither medication. Use of rate-control medications alone was not significantly associated with the composite outcome.

Among patients on dialysis with incident AF, use of antiarrhythmic medications may be associated with lower risk of stroke and death. Future randomized trials are needed to determine the efficacy and safety of antiarrhythmic medications in this high-risk population.