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DOACs in Patients With AF and Liver Disease
Study Questions:
What is the safety and efficacy of direct oral anticoagulant (DOAC) use among patients with nonvalvular atrial fibrillation (AF) and liver disease?
Methods:
Using the Korean National Health Insurance Service database, the authors identified patients with AF and liver disease being treated with any oral anticoagulant. Active liver disease was defined as an aspartate transaminase (AST) or alanine transaminase (ALT) level >2 times the upper limit of normal. Using inverse probability weighting, the authors compared patients treated with warfarin to those treated with DOACs. Outcomes assessed included ischemic stroke, intracranial hemorrhage (ICH), hospitalization for gastrointestinal and major bleeding, and all-cause death.
Results:
Among 12,778 warfarin-treated and 24,575 DOAC-treated patients with AF, DOAC use was associated with a lower risk of ischemic stroke (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.49-0.62), gastrointestinal bleeding (HR, 0.82; 95% CI, 0.62-0.95), major bleeding (HR, 0.65; 95% CI, 0.68-0.74), and all-cause death (HR, 0.61; 95% CI, 0.58-0.74). Among the 4,942 patients with active liver disease, DOAC use was associated with a lower risk of the composite endpoints (HR, 0.69; 95% CI, 0.58-0.83). This was similar to the risk reduction in the whole cohort (HR, 0.61; 95% CI, 0.57-0.66).
Conclusions:
The authors concluded that DOAC use showed effectiveness and safety as compared to warfarin in Asian patients with AF, including those with active liver disease.
Perspective:
DOAC therapy is not first-line for most patients with nonvalvular AF. However, FDA package inserts generally advise caution in patients with active liver disease. This retrospective analysis suggests that patients with active liver disease (elevated AST and/or ALT) likely experience similar stroke and bleeding risk reduction with DOAC therapy as compared to warfarin. However, only a minority of patients in this analysis had clinical cirrhosis, so extrapolation to that patient population should be cautioned.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Alanine Transaminase, Anticoagulants, Arrhythmias, Cardiac, Aspartate Aminotransferases, Atrial Fibrillation, Brain Ischemia, Gastrointestinal Hemorrhage, Intracranial Hemorrhages, Liver Cirrhosis, Liver Diseases, Risk Reduction Behavior, Secondary Prevention, Stroke, Warfarin, Vascular Diseases
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