Sudden death is one of the more frequent causes of death for hemodialysis patients, but the underlying mechanisms, contribution of arrhythmia, and associations with serum chemistries or the dialysis procedure are incompletely understood. To study this, implantable loop recorders were utilized for continuous cardiac rhythm monitoring to detect clinically significant arrhythmias including sustained ventricular tachycardia, bradycardia, asystole, or symptomatic arrhythmias in hemodialysis patients over six months. Serum chemistries were tested pre- and post-dialysis at least weekly. Dialysis procedure data were collected at every session. Associations with clinically significant arrhythmias were assessed using negative binomial regression modeling. Sixty-six patients were implanted and 1678 events were recorded in 44 patients. The majority were bradycardias (1461), with 14 episodes of asystole and only one of sustained ventricular tachycardia. Atrial fibrillation, although not defined as clinically significant arrhythmias, was detected in 41% of patients. With thrice-weekly dialysis, the rate was highest during the first dialysis session of the week and was increased during the last 12 hours of each inter-dialytic interval, particularly the long interval. Among serum and dialytic parameters, only higher pre-dialysis serum sodium and dialysate calcium over 2.5 mEq/L were independently associated with clinically significant arrhythmias. Thus, clinically significant arrhythmias are common in hemodialysis patients, and bradycardia and asystole rather than ventricular tachycardia may be key causes of sudden death in hemodialysis patients. Associations with the temporal pattern of dialysis suggest that modification of current dialysis practices could reduce the incidence of sudden death.

(ROCKET AF) trial, the efficacy and safety of rivaroxaban, a novel, oral, direct factor Xa inhibitor, was assessed for the prevention of stroke in patients with atrial fibrillation (AF) and at moderate to high risk of stroke.1 Results from this study showed that rivaroxaban (20 mg once daily or 15 mg once daily in patients with a creatinine clearance [CrCl] of 30-49 mL/min) was noninferior to dose-adjusted warfarin for the prevention of stroke and systemic embolism in an intention-to-treat (ITT) analysis. Rates of major or nonmajor clinically relevant bleeding were Background and Purpose-In Rivaroxaban Once Daily Oral Direct Factor Xa Inhibitor Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) trial, rivaroxaban was noninferior to dose-adjusted warfarin in preventing stroke or systemic embolism among patients with nonvalvular atrial fibrillation at moderate to high stroke risk. Because of differences in patient demographics, epidemiology, and stroke risk management in East Asia, outcomes and relative effects of rivaroxaban versus warfarin were assessed to determine consistency among East Asians versus other ROCKET AF participants. Methods-Baseline demographics and interaction of treatment effects of rivaroxaban and warfarin among patients within East Asia and outside were assessed. Results-A total of 932 (6.5%) ROCKET AF participants resided in East Asia. At baseline, East Asians had lower weight, creatinine clearance, and prior vitamin K antagonist use; higher prevalence of prior stroke; and less congestive heart failure and prior myocardial infarction than other participants. Despite higher absolute event rates for efficacy and safety outcomes in East Asians, the relative efficacy of rivaroxaban (20 mg once daily; 15 mg once daily for creatinine clearance of 30-49 mL/min) versus warfarin with respect to the primary efficacy end point (stroke/systemic embolism) was consistent among East Asians and non-East Asians (interaction P=0.666 2 The proportion of strokes that are hemorrhagic has also been shown to be higher in Asians than in whites.3,4 Conversely, there is evidence to suggest that cardioembolic strokes make up a greater proportion of strokes in white versus Asian populations.5 Data from 2 studies have also shown East Asian populations to be more sensitive to warfarin than Indian and white populations. 6,7 Warfarin may also interact with several food and herbal supplements commonly used in Asia, thereby complicating its use. 8There is a perception, and some supporting evidence, that the incidence of intracranial hemorrhage is increased in patients of Asian ethnicity (largely East Asian) who receive warfarin compared with other ethnic groups.9,10 As a result, anticoagulants are underprescribed 11,12 or underdosed 13 in patients within this region because of the fear that the risk of bleeding offsets any benefits.As a result of the differences in patient demographics, epidemiology, and stroke risk management in East Asia, outcomes and the rela...