OAC Treatment may be Clinically Beneficial in AF Patients with Concomitant Liver Disease

17 May, 21

Introduction

Presence of concomitant liver disease (LD) in patients with atrial fibrillation (AF) often leads to undertreatment with oral anticoagulation (OAC), due to the fear of life-threatening bleeding risk and also due to lack of strong evidence in the favor of the treatment.

Aim

To determine the impact of concomitant LD on AF patients, in terms of OAC prescription patterns and major adverse events.
To determine the impact of OAC treatment on major adverse events in specific patient subgroups

Patient Profile

Patients with AF who were hospitalized (age ≥40 years)
Based on the presence of LD, patients were classified as:
- AF with LD cohort (n=16,168)
- AF without LD cohort (n=377,339)

Methods

Study Design

A retrospective observational population-based cohort study

Assessments

Use of OAC was determined with Anatomical Therapeutic Chemical (ATC) codes

Outcomes

Stroke
Major bleeding
All-cause death

Follow-up Period

Minimum of one year

Results

At baseline, patients in the AF with LD cohort were less frequently treated with OAC as compared with patients with AF without LD [34.2% vs. 47.2%; p<0.001; odds ratio (OR); 0.96].
During a median follow-up time of 3.81 years, patients in the AF with LD cohort had an increased risk of all the study outcomes (Table 1)

Table 1: Major adverse events as per the history of LD

Outcome	AF with LD cohort	AF without LD cohort	*LD vs.* No LD**
Outcome	N=16,168	N=377,339	HR (95% CI)
Stroke	1,213	29,242	1.18 [1.11-1.25]
Major Bleeding	1,079	17,347	1.57 [1.47-1.66]
All-Cause Death	11,923	213,296	1.41 [1.39-1.44]

Use of OAC in patients with AF and LD was associated with a 20% risk reduction (RR) in stroke (HR: 0.80, 95% CI: 0.70-0.92), 14% RR in major bleeding (HR: 0.86, 95% CI: 0.74-0.99) and 23% RR in all-cause death (HR: 0.77, 95% CI: 0.73-0.80).
As per a net clinical benefit analysis, use of OAC was associated with a positive benefit/risk ratio in AF patients with LD (NCB: 0.408, 95% CI: 0.375-0.472).

Conclusions

AF patients with concomitant LD are burdened with a substantially higher risk for all clinical outcomes.
Use of OAC in AF patients with LD rendered a significant benefit/risk ratio, with clinical benefit, even in high-risk patients.
The findings favor the use of OACs in AF patients with concomitant LD, including those at high risk of major adverse events.

Eur Heart J Cardiovasc Pharmacother. 2021 Apr 9;7(FI1):f84-f92. doi: 10.1093/ehjcvp/pvaa015.