Safety of DOACs in patients with Child-Pugh Class C cirrhosis and atrial fibrillation

Area of Science:

• Cardiology
• Hepatology
• Pharmacology

Background:

• Anticoagulation (AC) is crucial for stroke prevention in atrial fibrillation (AF).
• Direct oral anticoagulants (DOACs) are established for AF patients without cirrhosis.
• Limited data exists on DOAC safety and efficacy in advanced cirrhosis (Child-Pugh class C).

Purpose of the Study:

• To evaluate the safety and outcomes of DOACs in patients with Child-Pugh class C cirrhosis and AF.
• To compare DOACs against no anticoagulation and warfarin in this patient population.

Main Methods:

• Utilized the TriNetX Database for patient data.
• Identified patients with Child-Pugh class C cirrhosis and AF.
• Created three cohorts: DOACs, no AC, and warfarin.
• Employed 1:1 propensity score matching (PSM) for cohort comparison.

Main Results:

• Compared AC vs. no AC: AC showed a significant 3-year mortality benefit (47% vs. 71%) and increased transplant status (17% vs. 5%). No significant difference in intracranial hemorrhage (ICH) or GI bleeding.
• Compared DOACs vs. no AC: DOACs demonstrated a mortality benefit (40% vs. 72%) and higher transplant rates (9% vs. 3.2%). ICH rates were higher with DOACs (6% vs. 4%).
• Compared DOACs vs. warfarin: DOACs showed significantly lower ICH risk (6.6% vs. 8.7%) and GI bleeding risk (2% vs. 2.4%).

Conclusions:

• Anticoagulation, including DOACs, appears safe and beneficial for patients with Child-Pugh class C cirrhosis and AF.
• DOACs represent a safer alternative to warfarin in this cohort, associated with reduced intracranial hemorrhage and gastrointestinal bleeding.
• Further research is warranted to fully elucidate the long-term safety and efficacy of DOACs in advanced liver disease.