Atrial fibrillation in patients with liver disease: Recent advances

Atrial fibrillation is associated with significant morbidity and mortality, and its incidence is increasing globally. The primary complication of atrial fibrillation is ischemic stroke, whose risk may be reduced with oral anticoagulant agents, i.e., either vitamin K antagonists or direct oral anticoagulants. Patients with atrial fibrillation often have concomitant hepatic impairment, particularly because of increasing rates of non-alcoholic liver disease. However, anticoagulation in patients with liver disease is challenging due to the pathophysiological changes of the coagulation cascade and, as a result, an increased risk of major bleeding in such individuals. Furthermore, monitoring of the degree of anticoagulation is complicated in patients with liver disease due to issues such as spontaneous international normalized ratio (INR) elevation, changes in hepatic drug elimination, and thrombocytopenia. We review the current evidence on atrial fibrillation and anticoagulation in patients with liver disease. We suggest having a strong focus on risk factor management and argue that the risk of ischemic stroke often outweighs the risk of hemorrhagic events in this setting

Atrial fibrillation in patients with liver disease:Recent advances

Atrial fibrillation is associated with significant morbidity and mortality, and its incidence is increasing globally. The primary complication of atrial fibrillation is ischemic stroke, whose risk may be reduced with oral anticoagulant agents, i.e., either vitamin K antagonists or direct oral anticoagulants. Patients with atrial fibrillation often have concomitant hepatic impairment, particularly because of increasing rates of non-alcoholic liver disease. However, anticoagulation in patients with liver disease is challenging due to the pathophysiological changes of the coagulation cascade and, as a result, an increased risk of major bleeding in such individuals. Furthermore, monitoring of the degree of anticoagulation is complicated in patients with liver disease due to issues such as spontaneous international normalized ratio (INR) elevation, changes in hepatic drug elimination, and thrombocytopenia. We review the current evidence on atrial fibrillation and anticoagulation in patients with liver disease. We suggest having a strong focus on risk factor management and argue that the risk of ischemic stroke often outweighs the risk of hemorrhagic events in this setting.</p

Ticagrelor or prasugrel vs. clopidogrel in patients with atrial fibrillation undergoing percutaneous coronary intervention for myocardial infarction

AIMS: The efficacy and safety of ticagrelor or prasugrel vs. clopidogrel in patients with atrial fibrillation (AF) on oral anticoagulation (OAC) undergoing percutaneous coronary intervention (PCI) for myocardial infarction (MI) have not been established.METHODS AND RESULTS: This was a nationwide cohort study of patients on OAC for AF who underwent PCI for MI from 2011 through 2019 and were prescribed a P2Y12 inhibitor at discharge. The primary efficacy outcome was major adverse cardiovascular events (MACE), defined as a composite of death from any cause, stroke, recurrent MI, or repeat revascularization. The primary safety outcome was cerebral, gastrointestinal, or urogenital bleeding requiring hospitalization. Absolute and relative risks for outcomes at 1 year were calculated through multivariable logistic regression with average treatment effect modelling. Outcomes were standardized for the individual components of the CHA2DS2-VASc and HAS-BLED scores as well as type of OAC, aspirin, and proton pump inhibitor use. We included 2259 patients of whom 1918 (84.9%) were prescribed clopidogrel and 341 (15.1%) ticagrelor or prasugrel. The standardized risk of MACE was significantly lower in the ticagrelor or prasugrel group compared with the clopidogrel group (standardized absolute risk, 16.3% vs. 19.4%; relative risk, 0.84, 95% confidence interval, 0.70-0.98; P = 0.02), while the risk of bleeding did not differ (standardized absolute risk, 5.5% vs. 5.1%; relative risk, 1.07, 95% confidence interval, 0.73-1.41; P = 0.69).CONCLUSION: In patients with AF on OAC who underwent PCI for MI, treatment with ticagrelor or prasugrel vs. clopidogrel was associated with reduced ischaemic risk, without a concomitantly increased bleeding risk.</p