Direct Oral Anticoagulant Type and Dose in Atrial Fibrillation With Decompensated Cirrhosis: A Propensity-Matched Analysis

Patients with atrial fibrillation (AF) and decompensated cirrhosis represent a high-risk population for anticoagulation, characterized by simultaneous susceptibility to thromboembolic and bleeding complications due to a rebalanced but unstable hemostatic state. These patients have been largely excluded from pivotal randomized trials of direct oral anticoagulants (DOACs), leaving limited evidence to guide drug selection or dosing in advanced liver disease.1,2 Although observational studies in the general AF population consistently demonstrate lower rates of major bleeding with apixaban compared with rivaroxaban, it remains unclear whether this advantage extends to patients with decompensated cirrhosis or whether reduced-dose DOAC regimens offer comparable safety and effectiveness to standard dosing in this setting.