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Anticoagulation in atrial fibrillation and liver disease: a pooled-analysis of >20 000 patients.

  • Chen, Shaojie1, 2
  • Pürerfellner, Helmut3
  • Meyer, Christian4, 5, 6, 7
  • Sommer, Philipp8
  • Kiuchi, Márcio Galindo9
  • Martinek, Martin3
  • Futyma, Piotr10
  • Zanchi, Simone11
  • Zhu, Lin12
  • Schratter, Alexandra13
  • Wang, Jiazhi14
  • Acou, Willem-Jan15
  • Liu, Shaowen16
  • Ling, Zhiyu17
  • Yin, Yuehui17
  • Ouyang, Feifan18
  • Chun, Julian K R1, 2
  • Schmidt, Boris1
  • 1 Cardioangiologisches Centrum Bethanien (CCB), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität Frankfurt am Main, Wilhelm-Epstein Straße 4, Frankfurt am Main 60431, Germany. , (Germany)
  • 2 Die Sektion Medizin, Universität zu Lübeck, Lübeck, Germany. , (Germany)
  • 3 Department für Kardiologie und Elektrophysiologie, Akademisches Lehrkrankenhaus, Ordensklinikum Linz Elisabethinen, Linz, Austria. , (Austria)
  • 4 Department of Cardiology, cNEP, Cardiac Neuro- & Electrophysiology Research Group, University Heart & Vascular Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany. , (Germany)
  • 5 DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany. , (Germany)
  • 6 Department of Cardiology, Evangelical Hospital Düsseldorf, Düsseldorf, Germany. , (Germany)
  • 7 Heinrich-Heine-University Hospital Düsseldorf, Düsseldorf, Germany. , (Germany)
  • 8 Klinik für Elektrophysiologie/Rhythmologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany. , (Germany)
  • 9 School of Medicine-Royal Perth Hospital Unit, University of Western Australia, Perth, Australia. , (Australia)
  • 10 St. Joseph's Heart Rhythm Center, Rzeszów, Poland. , (Poland)
  • 11 Division of Cardiology, Poliambulanza Institute Hospital Foundation, Brescia, Italy. , (Italy)
  • 12 Medizinisch-Geriatrische Klinik, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany. , (Germany)
  • 13 Medizinische Abteilung mit Kardiologie, Krankenhaus Hietzing Wien, Vienna, Austria. , (Austria)
  • 14 Intensivmedizin, Charité-Universitätsmedizin Berlin, Berlin, Germany. , (Germany)
  • 15 Department of Cardiology, AZ Delta, Roeselare, Belgium. , (Belgium)
  • 16 Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. , (China)
  • 17 Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China. , (China)
  • 18 Klinik und Poliklinik für Kardiologie, Universitäres Herz und Gefäßzentrum, Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg, Germany. , (Germany)
Published Article
European heart journal. Cardiovascular pharmacotherapy
Publication Date
Jun 08, 2022
DOI: 10.1093/ehjcvp/pvab032
PMID: 33871577


Anticoagulation for atrial fibrillation patients with liver disease represents a clinical dilemma. We sought to evaluate the efficacy/safety of different anticoagulation, i.e. vitamin K antagonist (VKA) and non-VKA oral anticoagulants (NOACs) in such patient group. This was a pooled-analysis enrolling up-to-date clinical data. Two subsets: subset A (VKA vs. Non-Anticoagulation) and subset B (NOACs vs. VKA) were pre-specified. The study outcomes were ischaemic stroke (IS)/thromboembolism (TE), major bleeding (MB), intracranial bleeding (ICB), gastrointestinal bleeding (GIB), and all-cause mortality. A total of 20 042 patients' data were analysed (subset A: N = 10 275, subset B: N = 9767). Overall mean age: 71 ± 11 years, mean CHA2DS2-VASc score: 4.0 ± 1.8, mean HAS-BLED score: 3.6 ± 1.2. The majority of the patients had Child-Pugh category (A-B). As compared with Non-Anticoagulation, VKA seemed to reduce the risk of IS/TE [odds ratio (OR): 0.60, P = 0.05], but heighten the risk of all-bleeding events including MB (OR: 2.81, P = 0.01), ICB (OR: 1.60, P = 0.01), and GIB (OR: 3.32, P = 0.01). When compared with VKA, NOACs had similar efficacy in reducing the risk of IS/TE (OR: 0.82, P = 0.64), significantly lower risk of MB (OR: 0.54, P = 0.0003) and ICB (OR: 0.35, P < 0.0001), and trend towards reduced risk of GIB (OR: 0.72, P = 0.12) and all-cause mortality (OR: 0.79, P = 0.35). The favourable effects were maintained in subgroups of individual NOAC. VKA appears to reduce the risk of IS/TE but increase all-bleeding events. NOACs have similar effect in reducing the risk of IS/TE and have significantly lower risk of MB and ICB as compared with VKA. NOACs seem to be associated with better clinical outcome than VKA in patients with mild-moderate liver disease. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

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