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Published on: February 26, 2013
Assessing Safety of Anticoagulation for Atrial Fibrillation in Patients with Cirrhosis: A Real-World Outcomes Study
Justin J Song1, Nicholas J Jackson1, Helen Shang1
1Department of Medicine, UCLA Medical Center, Los Angeles, USA.
Insights
Anticoagulation in patients with atrial fibrillation and cirrhosis increases hospital and ICU admissions but does not raise mortality or transfusion risks. Direct oral anticoagulants showed higher hospital admission risks than warfarin.
Area of Science:
- Cardiology
- Hepatology
- Clinical Pharmacology
Background:
- Randomized trials show anticoagulation reduces ischemic stroke in atrial fibrillation (AF).
- Trials excluded patients with significant liver disease, necessitating extrapolation of guidelines.
- The impact of anticoagulation on safety events in AF patients with cirrhosis is unevaluated.
Purpose of the Study:
- To evaluate the safety of anticoagulation in patients with atrial fibrillation and cirrhosis.
- To assess the association between anticoagulation strategies and adverse safety events in this population.
Main Methods:
- Retrospective cohort study using de-identified health records.
- Propensity score matching and weighting were used to compare anticoagulation strategies.
- Outcomes included mortality, transfusion requirements, and hospital/ICU admissions.
Main Results:
- Anticoagulation was associated with increased hospital admission count (OR=1.74) and risk (OR=1.54), and ICU admission risk (OR=1.41).
- No significant differences were found in mortality, transfusion needs, or length of stay.
- Direct oral anticoagulants (DOACs) showed higher hospital admission risks compared to warfarin and no anticoagulation.
Conclusions:
- Anticoagulation in AF patients with cirrhosis is linked to higher hospital and ICU admission rates.
- Anticoagulation did not increase mortality or transfusion requirements in this cohort.
- DOACs were associated with increased hospital admission risk compared to warfarin and no anticoagulation.
Aims:
In patients with atrial fibrillation (AF) and stroke risk factors, randomized trials have demonstrated that anticoagulation decreases the risk of ischemic stroke. However, all trials to date have excluded patients with significant liver disease, leaving guidelines to extrapolate recommendations. We aim to evaluate the impact of anticoagulation on safety events in patients with AF and cirrhosis.
Methods And Results:
In this retrospective cohort study, we obtained de-identified health record data to extract anticoagulation strategy, comorbidities, prescriptions, lab values, and procedures for a cohort of patients with cirrhosis who develop AF. After selecting a propensity matched population to match patients with various anticoagulation strategies, we tracked data on outcomes for death, transfusion requirements, hospital and ICU admissions. After propensity score weighting and multivariable adjustment, anticoagulation strategy was associated with increased hospital admission count (OR = 1.74 per admission, P < .001), binary risk of hospital admission (OR = 1.54, P = .010) and risk of ICU admission (OR = 1.41, P = .047). We detected no significant differences in mortality, transfusion of blood products, or average length of stay. Direct oral anticoagulant (DOAC) prescriptions were associated with increased binary risk of hospital admission compared to warfarin prescriptions. In a third comparison, DOAC strategy alone was associated with increased hospital admission count (OR = 1.41 per admission, P < .001) and binary risk of hospital admission (OR = 1.52, P = .038) compared to no anticoagulation strategy.
Conclusion:
Anticoagulation strategy in patients with cirrhosis and AF was associated with increased rate of hospital admission and ICU admission but not associated with increased risk of mortality or transfusion requirement.
