Thromboembolism and bleeding in patients with atrial fibrillation and liver disease – A nationwide register-based cohort study

Steensig, Kamilla; Pareek, Manan; Krarup, Anne Lund; Søgaard, Peter; Mæng, Michael; Tayal, Bhupendar; Lee, Christina Ji-Young; Torp‐Pedersen, Christian; Lip, Gregory Y.H.; Holland-Fischer, Peter; Kragholm, Kristian

doi:10.1016/j.clinre.2022.101952

Cited by 7 publications

(3 citation statements)

References 33 publications

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“…Notably, despite having a CHA 2 DS 2 -VASc score of ≥2, more than 90% of liver cirrhosis patients included in the study received either no treatment or treatment with a platelet inhibitor instead of OACs. Supporting the Taiwanese study, a Danish, nationwide, cohort study by Steensig et al also reported a benefit of OACs in individuals with liver disease and AF, though only in the case of a CHA 2 DS 2 -VASc score of ≥2 for men and ≥3 for women [79] The authors included a total of 1238 OAC naïve patients with liver disease, newly diagnosed atrial fibrillation, and a CHA 2 DS 2 -VASc score of ≥1 for men and ≥2 for women and compared initiation of OACs with no OACs. Initiation of OACs was associated with significantly reduced risk of thromboembolism, and the positive effect of OAC increased with the rising CHA 2 DS 2 -VASc score.…”

Section: Observational Evidence On Oral Anticoagulant Treatment In Pa...mentioning

confidence: 88%

Atrial fibrillation in patients with liver disease: Recent advances

Godtfredsen,

Kragholm,

Pareek

2023

Kardiol Pol

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Atrial fibrillation is associated with significant morbidity and mortality, and its incidence is increasing globally. The primary complication of atrial fibrillation is ischemic stroke, whose risk may be reduced with oral anticoagulant agents, i.e., either vitamin K antagonists or direct oral anticoagulants. Patients with atrial fibrillation often have concomitant hepatic impairment, particularly because of increasing rates of non-alcoholic liver disease. However, anticoagulation in patients with liver disease is challenging due to the pathophysiological changes of the coagulation cascade and, as a result, an increased risk of major bleeding in such individuals. Furthermore, monitoring of the degree of anticoagulation is complicated in patients with liver disease due to issues such as spontaneous international normalized ratio (INR) elevation, changes in hepatic drug elimination, and thrombocytopenia. We review the current evidence on atrial fibrillation and anticoagulation in patients with liver disease. We suggest having a strong focus on risk factor management and argue that the risk of ischemic stroke often outweighs the risk of hemorrhagic events in this setting.

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Section: Observational Evidence On Oral Anticoagulant Treatment In Pa...mentioning

confidence: 88%

Atrial fibrillation in patients with liver disease: Recent advances

Godtfredsen,

Kragholm,

Pareek

2023

Kardiol Pol

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“…In a prospective cohort, Pastori et al [ 34 ] confirmed that patients with AF and advanced liver fibrosis, defined on prophylactic treatment with VKAs, have an increased risk of ischemic cardiovascular events, including ischemic stroke, compared with those treated with DOACs [ 18 ]. Until now, there have been no studies evaluating the role of anticoagulant treatment in stroke prevention in patients with AF and decompensated LC, although it has been demonstrated that cirrhotic men with CHA2DS2-VASc scores ≥2 and women with CHA2DS2-VASc scores ≥3 benefit more from the anticoagulant treatment in regard of thromboembolic events prevention [ 71 ].…”

Section: Anticoagulant Prophylaxis In Patients With Decompensated Liv...mentioning

confidence: 99%

Anticoagulation for Atrial Fibrillation in Patients with Decompensated Liver Cirrhosis: Bold and Brave?

et al. 2023

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Atrial fibrillation is frequently diagnosed in patients with liver cirrhosis, especially in those with non-alcoholic steatohepatitis or alcoholic etiology. Anticoagulant treatment is recommended for thromboembolic protection in patients with atrial fibrillation. Considering the impaired coagulation balance in liver cirrhosis, predisposing patients to bleed or thrombotic events, the anticoagulant treatment is still a matter of debate. Although patients with liver cirrhosis were excluded from the pivotal studies that confirmed the efficacy and safety of the anticoagulant treatment in patients with atrial fibrillation, data from real-life cohorts demonstrated that the anticoagulant treatment in patients with liver cirrhosis could be safe. This review aimed to evaluate the recent data regarding the safety and efficacy of anticoagulant treatment in patients with decompensated liver cirrhosis. Direct oral anticoagulants are safer than warfarin in patients with compensated liver cirrhosis. In Child–Pugh class C liver cirrhosis, direct oral anticoagulants are contraindicated. New bleeding and ischemic risk scores should be developed especially for patients with liver cirrhosis, and biomarkers for bleeding complications should be implemented in clinical practice to personalize this treatment in a very difficult population represented by decompensated liver cirrhosis patients.

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“…An analysis of 1238 Danish citizens with new-onset AF and CLD reported that, for patients with a CHA 2 DS 2 -VASc-score ≥2, 5-year thromboembolism rates were significantly lower in patients receiving anticoagulation (16% versus 24%; average risk ratio, 0.66 [95% CI, 0.45–0.87]). 9 Bleeding risks were higher among patients with cirrhotic than with noncirrhotic disease, but this was not significantly affected by anticoagulant status (oral anticoagulation versus none: cirrhosis, average risk ratio 0.72 [95% CI, 0.28–1.15]; no cirrhosis, average risk ratio 1.28 [95% CI, 0.67–1.90]). Similarly, a retrospective analysis of 16 168 patients from Italy with AF and liver disease demonstrated that liver disease was associated with an elevated risk of major bleeding, but oral anticoagulant use resulted in a reduction in risk of stroke (hazard ratio [HR], 0.80 [95% CI, 0.70–0.92]) and major bleeding (HR, 0.86 [95% CI, 0.74–0.99]).…”

mentioning

confidence: 95%