Anticoagulation with warfarin (HR 0.65; 95% CI 0.55-0.76) or DOACs (HR 0.68; 95% CI 0.50-0.93) was associated with reduced all-cause mortality compared to no anticoagulation in cirrhosis and AF.
Cohort (n=2,694)
Yes
Does anticoagulation with warfarin or DOACs reduce all-cause mortality and ischemic stroke in patients with cirrhosis and atrial fibrillation?
In veterans with cirrhosis and atrial fibrillation, anticoagulation with warfarin or DOACs is associated with reduced all-cause mortality and ischemic stroke, with DOACs showing a lower bleeding risk than warfarin.
Effect estimate: HR 0.65 (95% CI 0.55-0.76)
BACKGROUND AND AIMS: Outcomes with anticoagulation (AC) are understudied in advanced liver disease. We investigated effects of AC with warfarin and direct oral anticoagulants (DOACs) on all-cause mortality and hepatic decompensation as well as ischemic stroke, major adverse cardiovascular events, splanchnic vein thrombosis, and bleeding in a cohort with cirrhosis and atrial fibrillation (AF). APPROACH AND RESULTS: This was a retrospective, longitudinal study using national data of U.S. veterans with cirrhosis at 128 medical centers, including patients with cirrhosis with incident AF, from January 1, 2012 to December 31, 2017 followed through December 31, 2018. To assess the effects of AC on outcomes, we applied propensity score (PS) matching and marginal structural models (MSMs) to account for confounding by indication and time-dependent confounding. The final cohort included 2,694 veterans with cirrhosis with AF (n = 1,694 and n = 704 in the warfarin and DOAC cohorts after PS matching, respectively) with a median of 4.6 years of follow-up. All-cause mortality was lower with warfarin versus no AC (PS matched: hazard ratio HR, 0.65; 95% confidence interval CI, 0.55-0.76; MSM models: HR, 0.54; 95% CI, 0.40-0.73) and DOACs versus no AC (PS matched: HR, 0.68; 95% CI, 0.50-0.93; MSM models: HR, 0.50; 95% CI, 0.31-0.81). In MSM models, warfarin (HR, 0.29; 95% CI, 0.09-0.90) and DOACs (HR, 0.23; 95% CI, 0.07-0.79) were associated with reduced ischemic stroke. In secondary analyses, bleeding was lower with DOACs compared to warfarin (HR, 0.49; 95% CI, 0.26-0.94). CONCLUSIONS: Warfarin and DOACs were associated with reduced all-cause mortality. Warfarin was associated with more bleeding compared to no AC. DOACs had a lower incidence of bleeding compared to warfarin in exploratory analyses. Future studies should prospectively investigate these observed associations.
Serper et al. (Wed,) conducted a cohort in Cirrhosis and atrial fibrillation (n=2,694). Anticoagulation (warfarin and DOACs) vs. No anticoagulation was evaluated on All-cause mortality (HR 0.65, 95% CI 0.55-0.76). Anticoagulation with warfarin (HR 0.65; 95% CI 0.55-0.76) or DOACs (HR 0.68; 95% CI 0.50-0.93) was associated with reduced all-cause mortality compared to no anticoagulation in cirrhosis and AF.