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

Background: Balancing the risk of thromboembolism and bleeding in patients with liver disease and atrial fibrillation/flutter is particularly challenging.Purpose: To examine the risks of thromboembolism and bleeding with use/non-use of oral anti-coagulation (including vitamin K-antagonists and direct oral anticoagulants) in patients with liver disease and AF.Methods: Danish nationwide register-based cohort study of anticoagulant naive individuals with liver disease, incident atrial fibrillation/flutter, and a CHA2DS2-VASc-score>1 (men) or >2 (women), alive 30 days after atrial fibrillation/flutter diagnosis. Thromboembolism was a com-posite of ischaemic stroke, transient ischaemic attack, or venous thromboembolism. Bleeding was a composite of gastrointestinal, intracerebral, or urogenital bleeding requiring hospitalisa-tion, or epistaxis requiring emergency department visit or hospital admission. Cause-specific Cox-regression was used to estimate absolute risks and average risk ratios standardised to covari-ate distributions. Because of significant interactions with anticoagulants, results for thromboem-bolism were stratified for CHA2DS2-VASc-score, and results for bleeding were stratified for cirrhotic/non-cirrhotic liver disease. Results: Four hundred and nine of 1,238 patients with liver disease and new atrial fibrillation/ flutter initiated anticoagulants. Amongst patients with a CHA2DS2-VASc-score of 1-2 (2-3 for women), five-year thromboembolism incidence rates were low and similar in the anticoagulant (6.5%) versus no anticoagulant (5.5%) groups (average risk ratio 1.19 [95%CI, 0.22-2.16]). In patients with a CHA2DS2-VASc-score>2 (>3 for women), incidence rates were 16% versus 24% (average risk ratio 0.66 [95%CI, 0.45-0.87]). Bleeding risks appeared higher amongst patients with cirrhotic versus non-cirrhotic disease but were not significantly affected by anticoagulant status.Conclusion: Oral anticoagulant initiation in patients with liver disease, incident new atrial fibril-lation/flutter, and a high CHA2DS2-VASc-score was associated with a reduced thromboembolism risk. Bleeding risk was not increased with anticoagulation, irrespective of the type of liver dis-ease.(c) 2022 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Automated summary

This study examined the risks of thromboembolism and bleeding in patients with liver disease and atrial fibrillation/flutter who used or did not use oral anticoagulation. The results showed that oral anticoagulant initiation was associated with a reduced thromboembolism risk in patients with liver disease and high CHA2DS2-VASc-score.