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July 26, 2026Journal of Thrombosis and ThrombolysisOpen Access

DOACs linked to ~21% less hepatic decompensation and reduced mortality versus warfarin in cirrhotic AF.

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Why the study?

Anticoagulation in patients with AF and liver cirrhosis is challenging due to competing thrombosis and bleeding risks, and the comparative safety and effectiveness of DOACs versus warfarin remain incompletely defined.

Do direct oral anticoagulants reduce hepatic decompensation and ischemic stroke in adult patients with atrial fibrillation and liver cirrhosis compared to warfarin?

Population

5,044 adult patients with AF and liver cirrhosis

Comparison

DOACs vs warfarin

Design

Retrospective propensity score matched cohort study

Follow-up

1 year

Key result

Direct oral anticoagulants were associated with a significantly lower risk of hepatic decompensation (HR 0.79) and all-cause mortality compared to warfarin in patients with atrial fibrillation and liver cirrhosis.

Authors

FAF AhmedSKSaifullah KhanNGNajam Gohar

Discussion

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Member takes

Overview

Supports the safety of DOACs over warfarin in cirrhotic patients with AF; leaves.

Key Points

  • This research examines the safety and effectiveness of direct oral anticoagulants compared to warfarin in patients with atrial fibrillation and liver cirrhosis.
  • Retrospective cohort study utilizing the TriNetX Global Collaborative Network.
  • Adult patients (≥ 18 years) with AF and cirrhosis were matched 1:1 based on propensity scores.
  • Primary outcomes analyzed included hepatic decompensation and ischemic stroke within 1 year.
  • Hepatic decompensation occurred in 8.8% of DOAC patients vs. 11.1% of warfarin patients (HR 0.79, 95% CI 0.67-0.95; p=0.010).
  • Ischemic stroke rates were 2.9% for DOAC and 2.4% for warfarin (HR 1.22, 95% CI 0.85-1.75; p=0.289).
  • All-cause mortality was lower in the DOAC group (17.7% vs. 20.3%; HR 0.87, 95% CI 0.77-0.99; p=0.035).

Study Design

Type

Cohort (n=5,044)

Multicenter

Yes

Structured PICO

Do direct oral anticoagulants reduce hepatic decompensation and ischemic stroke in adult patients with atrial fibrillation and liver cirrhosis compared to warfarin?

P
Population
5,044 adult patients with atrial fibrillation, liver cirrhosis, and portal hypertension, propensity-score matched to compare DOACs versus warfarin, followed for 1 year.
E
Exposure
Direct oral anticoagulants (DOACs)
C
Comparator
Warfarin (propensity score matched 1:1)
O
Outcome
Hepatic decompensation and ischemic stroke within 1 yearhard clinical

Main Result

Hazard Ratio: 0.79 (95% CI 0.67–0.95)

Absolute Event Rate: 8.8% vs 11.1%

p-value: p=0.010

In patients with atrial fibrillation and liver cirrhosis, DOACs are associated with lower risks of hepatic decompensation and all-cause mortality compared to warfarin, without increasing bleeding or stroke risks.

Limitations

  • Observational design precludes causal inference
  • Residual confounding due to unmeasured factors such as liver disease severity and bleeding risk
  • Lack of formal cirrhosis severity measures (Child-Pugh, MELD) in the database
  • Outcomes relied on ICD codes without independent clinical validation
  • Use of a composite endpoint may obscure differential effects across individual hepatic events
  • One-year follow-up may be insufficient to capture long-term hepatic outcomes
  • Observational design
  • Modest absolute differences

Cite This Study

Ahmed et al. (2026) conducted a cohort in Atrial fibrillation and liver cirrhosis (n=5,044). Direct oral anticoagulants (DOACs) vs. Warfarin was evaluated on Hepatic decompensation within 1 year (HR 0.79, 95% CI 0.67-0.95, p=0.010). Direct oral anticoagulants were associated with a significantly lower risk of hepatic decompensation (HR 0.79) and all-cause mortality compared to warfarin in patients with atrial fibrillation and liver cirrhosis.

synapsesocial.com/papers/6a65a306d3aea3239cd7655bhttps://doi.org/10.1007/s11239-026-03359-4
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