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Particularities of Noac in Atrial Fibrillation Associated With liver Cirrhosis

Ana-Maria Dumitrescu1, Anca Sava1,Elena Adorata Coman2, Claudia Florida Costea3*, Raluca AnaMaria Mogos4, Simona Juliette Mogos5, Raluca Dragomir6,Iustina Petra Solomon Condriuc4, Iuliana Magdalena Stârcea7,Andrei-Ionut Cucu8, Maria Magdalena Leon Constantin9, Florin Mitu9, Lucia Corina Dima-Cozma9

Introduction: Patients with liver cirrhosis (LC) have a higher prevalence of atrial fibrillation (AFI) than the general population. If until the beginning of the 21^st century, anticoagulant treatment in LC involved the use of low molecular weight heparins and vitamin K antagonists (VKAs) the possible administration of new oral anticoagulants (NOACs) is currently being investigated.

Purpose of the study: The present study investigates the efficacy and safety of NOACs use in patients with LC and AFI, by analyzing the literature.

Methods and materials: We conducted an extensive literature search to identify studies that report AFI anticoagulant therapy in patients with liver cirrhosis. The search was conducted in MEDLINE, Google Scholar, and PubMed and Thompson ISI in order to identify articles in English on this topic. To find relevant up-to-date data on the peculiarities of NOACs in AFI associated with cirrhosis, we used the following as keywords for current research: "atrial fibrillation", "liver cirrhosis", "anticoagulation”, “direct-acting anticoagulants". Out of a total of 43 abstracts, only 36 full articles were considered that were directly related to the research topic, such as reviews or meta-analysis, published between 2008 and 2022, over a period of 14 years.

Results: NOACs have superior pharmacological characteristics to VKAs, but have a number of side effects that should be considered when administering to patients with AFI and decompensated LC. To date, there are several trials that have shown that since Dabigatran, Rivaroxaban, Apixaban and Edoxaban are metabolized in both the kidneys and the liver, patients with LC and AFI should be monitored continuously for their liver and kidney function. The use of NOACs is a reasonable alternative to VKAs in patients with LC and AFI, but the severity of liver disease should be considered, as anticoagulation is effective in patients with LC class Child-Pugh A, but is not recommended for those in Child-Pugh C class. In patients with moderate hepatic impairment (Child-Pugh B), NOACs are variably recommended.

Conclusion: More and more data have appeared in recent years that seem to encourage the administration of new oral anticoagulants in patients with decompensated liver cirrhosis and atrial fibrillation as these new coagulants seem to offer a benefit over VKAs.