The safety and efficacy of vitamin K antagonist in patients with atrial fibrillation and liver cirrhosis

Background: Bleeding is a major concern in treatment of atrial fibrillation (AF) with vitamin K antagonist (VKA). This concern is more emphasized in patients with high bleeding risk such as liver cirrhosis (LC). Methods and results: We retrospectively analyzed incidence of stroke and major bleeding in 321 AF patients with LC, including early [Child-Pugh (CP)-A, n = 215] and advanced [CP-B or C, n = 106] LC according to VKA prescription. The CHA(2)DS(2)-VASc, HAS-BLED and MELD scores were higher in patients with VKA. CP score was positively correlated with HAS-BLED score (rho: 0.602). The incidence of major bleeding was higher in advanced LC than in early LC (14.5%/year vs. 4.9%/year, p < 0.001). VKA reduced the risk of ischemic stroke in AF patients with LC, whereas it significantly increased the major bleeding risk. There was no difference in survival free from significant clinical events (SCEs) between the patients with or without VKA (p = 0.91). On subgroup analysis, VKA was beneficial in early LC patients, as it decreased stroke without increasing major bleeding risk. However, in advanced LC patients, VKA significantly increased the risk of major bleeding, especially variceal origin, that overwhelms stroke reduction. As a result, VKA treatment reduced the risk of SCEs in early LC patients, whereas it increased the risk of SCEs in advanced LC. Conclusions: VKA treatment might be beneficial to reduce significant clinical events in the early LC but not in the advanced LC group. However to confirm this hypothesis, a prospective randomized study is needed. (C) 2014 Elsevier Ireland Ltd. All rights reserved.