Safety of direct oral anticoagulants vs warfarin in patients with chronic liver disease and atrial fibrillation

Background: A complication of chronic liver disease (CLD) is the abnormality of coagulation. In clinical practice, this increased risk of bleeding has not been identified as a protective factor against stroke or systemic embolism associated with atrial fibrillation (AF). The objective of this study was to assess the safety of direct oral anticoagulant (DOAC) agents vs warfarin in CLD patients with AF. Methods: This was a retrospective cohort study of patients with CLD and AF initiated on oral anticoagulants. Rates of all-cause bleeding were compared between warfarin and DOAC agents. Secondary endpoints included rates of major bleeding and other risk factors for bleeding on anticoagulant therapy. Results: The all-cause bleeding rates were similar between the groups, with 8.4% per year in the DOAC (n = 75) group and 8.8% in warfarin (n = 158) group (HR 0.9, 95% CI 0.4-1.8). No significant difference was noted in the rate of major bleeding. In the multivariable model, higher MELD-XI score and previous bleed were risk factors associated with increased bleeding. Conclusion: No significant differences in bleeding rates were noted in patients treated with warfarin and DOAC agents. Further studies evaluating DOAC agents are needed to better understand the optimal anticoagulation strategy in setting of CLD.