Journal of the American College of Cardiology (JACC)Apixaban, Rivaroxaban, and Warfarin in Patients with Cirrhosis and AF

Apixaban Shows Lower Bleeding Risk in Cirrhosis Patients with AF: Implications for Anticoagulation Management in Liver Disease

A recent population-based cohort study has provided new insights into the safety and effectiveness of oral anticoagulants in patients with both cirrhosis and atrial fibrillation (AF). The study, which analyzed data from two US claims databases, compared outcomes among patients initiating apixaban, rivaroxaban, or warfarin. The findings suggest that apixaban may offer a more favorable safety profile in terms of major bleeding events, particularly when compared to rivaroxaban and warfarin, while maintaining similar efficacy in preventing thromboembolic events.

Key Points:

• The study included two propensity-matched cohorts: 2,785 pairs of apixaban vs. rivaroxaban users and 2,852 pairs of apixaban vs. warfarin users.
• Patients initiating rivaroxaban had a higher rate of major hemorrhage compared to apixaban (rate difference: 33.1/1,000 patient-years; 95% CI, 12.9-53.2; HR, 1.47; 95% CI, 1.11-1.94).
• Warfarin initiators also showed a higher rate of major hemorrhage compared to apixaban users (rate difference: 26.1/1,000 patient-years; 95% CI, 6.8-45.3; HR, 1.38; 95% CI, 1.03-1.84).
• A notable increase in hemorrhagic stroke risk was observed with warfarin compared to apixaban (rate difference: 9.47/1,000 patient-years, 95% CI, 2.2-17.2; HR, 2.85; 95% CI, 1.24-6.59).
• No significant differences were found in the rates of ischemic events or death between apixaban and either rivaroxaban or warfarin.
• Approximately one-third of the study cohort had a history of prior hepatic decompensation.
• About 15-20% of patients showed evidence of ascites or hepatorenal syndrome.
• The results may be most applicable to patients with mild to moderate chronic liver disease (eg, Child-Pugh Class A-B).
• The findings support current recommendations favoring direct oral anticoagulants, particularly apixaban, over warfarin for most patients with AF.
• The study provides reassurance for clinicians managing anticoagulation in patients with less severe forms of cirrhosis and AF.

HCN Medical Memo
This study provides valuable evidence supporting the use of apixaban as a preferred anticoagulant for patients with cirrhosis and atrial fibrillation, particularly those with mild to moderate liver disease. The lower bleeding risk associated with apixaban, compared to rivaroxaban and warfarin, offers a potentially safer option for this complex patient population. However, clinicians should still exercise caution and individualize treatment decisions, especially for patients with more advanced cirrhosis.

More on Afib