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Observational Study
. 2017 Jun 23;6(6):e005307.
doi: 10.1161/JAHA.116.005307.

Liver Cirrhosis in Patients With Atrial Fibrillation: Would Oral Anticoagulation Have a Net Clinical Benefit for Stroke Prevention?

Ling Kuo  1   2   3 , Tze-Fan Chao  4   2   3 , Chia-Jen Liu  5   6 , Yenn-Jiang Lin  1   2   3 , Shih-Lin Chang  1   2   3 , Li-Wei Lo  1   2   3 , Yu-Feng Hu  1   2   3 , Ta-Chuan Tuan  1   2   3 , Jo-Nan Liao  1   2   3 , Fa-Po Chung  1   2   3 , Tzeng-Ji Chen  7 , Gregory Y H Lip  8 , Shih-Ann Chen  1   2   3
Affiliations
Observational Study

Liver Cirrhosis in Patients With Atrial Fibrillation: Would Oral Anticoagulation Have a Net Clinical Benefit for Stroke Prevention?

Ling Kuo et al. J Am Heart Assoc. .

Abstract

Background: Patients with liver cirrhosis have been excluded from randomized clinical trials of oral anticoagulation therapy for stroke prevention in atrial fibrillation. We hypothesized that patients with liver cirrhosis would have a positive net clinical benefit for oral anticoagulation when used for stroke prevention in atrial fibrillation.

Methods and results: This study used the National Health Insurance Research Database in Taiwan. Among 289 559 atrial fibrillation patients aged ≥20 years, there were 10 336 with liver cirrhosis, and 9056 of them having a CHA2DS2-VASc score ≥2 were divided into 3 groups, that is, no treatment, antiplatelet therapy, and warfarin. Patients with liver cirrhosis had a higher risk of ischemic stroke (hazard ratio=1.10, P=0.046) and intracranial hemorrhage (hazard ratio=1.20, P=0.043) compared with those without. Among patients with liver cirrhosis, patients taking antiplatelet therapy had a similar risk of ischemic stroke (hazard ratio=1.02, 95%CI=0.88-1.18) compared to those without antithrombotic therapies, but the risk was significantly lowered among warfarin users (hazard ratio=0.76, 95%CI=0.58-0.99). For intracranial hemorrhage, there were no significant differences between those untreated and those taking antiplatelet therapy or warfarin. The use of warfarin was associated with a positive net clinical benefit compared with being untreated or receiving only antiplatelet therapy.

Conclusions: For atrial fibrillation patients with liver cirrhosis in the current analysis of an observational study, warfarin use was associated with a lower risk of ischemic stroke and a positive net clinical benefit compared with nontreatment, and thus, thromboprophylaxis should be considered for such patients.

Keywords: atrial fibrillation; intracranial hemorrhage; ischemic stroke; liver cirrhosis.

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Figures

Figure 1
Figure 1
A flowchart of the enrollment of the study cohort. From January 1, 2000 to December 31, 2011, a total of 289 559 AF patients aged ≥20 years (10 336 with liver cirrhosis) were identified from the NHIRD. The risks of ischemic stroke and ICH were compared for patients with and without liver cirrhosis. Among 10 336 patients with liver cirrhosis, 9056 had a CHA 2 DS 2‐VASc score ≥2. These were divided into 3 groups, that is, no treatment (61.1%), antiplatelet therapy (30.6%), and warfarin (8.3%). The risk of ICH and benefit of stroke risk reduction were analyzed between patients without use of any anti‐thrombotic agent and those with anti‐platelet agents or warfarin use. AF indicates atrial fibrillation; ICH, intracranial hemorrhage; NHIRD, National Health Insurance Research Database.
Figure 2
Figure 2
Risk of ischemic stroke and ICH for AF patients with or without liver cirrhosis, stratified based on the strategies for stroke prevention. For patients who did not receive antithrombotic therapies, the risk of ischemic stroke and ICH was higher for AF patients with liver cirrhosis compared with those without. For patients treated with warfarin, the risk of ischemic stroke and ICH was similar between patients with or without liver cirrhosis. The hazard ratio was adjusted for age, sex, CHA 2 DS 2‐VASc score, COPD, hyperlipidemia, malignancy, autoimmune diseases, end‐stage renal disease, degree of urbanization, and income level. CI indicates confidence interval; ICH, intracranial hemorrhage.
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References

    1. Shepard CW, Finelli L, Alter MJ. Global epidemiology of hepatitis C virus infection. Lancet Infect Dis. 2005;5:558–567. - PubMed
    1. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor‐based approach: the Euro Heart Survey on Atrial Fibrillation. Chest. 2010;137:263–272. - PubMed
    1. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user‐friendly score (HAS‐BLED) to assess 1‐year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;138:1093–1100. - PubMed
    1. Lip GY, Skjoth F, Nielsen PB, Larsen TB. Non‐valvular atrial fibrillation patients with none or one additional risk factor of the CHA2DS2‐VASc score. A comprehensive net clinical benefit analysis for warfarin, aspirin, or no therapy. Thromb Haemost. 2015;114:826–834. - PubMed
    1. Chao TF, Liu CJ, Wang KL, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chen TJ, Lip GY, Chen SA. Using the CHA2DS2‐VASc score for refining stroke risk stratification in “low‐risk” Asian patients with atrial fibrillation. J Am Coll Cardiol. 2014;64:1658–1665. - PubMed

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