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Direct oral anticoagulants benefit Asian population with AF, liver disease
Direct oral anticoagulant use was more effective and safer than warfarin in a large Asian population with atrial fibrillation and liver disease, according to findings published in the Journal of the American College of Cardiology.
Researchers also reported that the benefits observed with direct oral anticoagulants vs. warfarin were consistent among patients with significant active liver disease.
So-Ryoung Lee, MD, of the division of cardiology in the department of internal medicine at Seoul National University Hospital in South Korea, and colleagues analyzed patients with nonvalvular AF and active liver disease who were treated with oral anticoagulants in the Korean National Health Insurance database. Of those, 12,778 were treated with warfarin and 24,575 were treated with direct oral anticoagulants.
“Previous pivotal randomized clinical trials have shown the benefit of direct oral anticoagulants over warfarin in stroke prevention and reducing the risk of major bleeding in patients with AF,” Eue-Keun Choi, MD, PhD, associate professor at Seoul National University Hospital, told Cardiology Today. “However, strict criteria to exclude patients with significant active liver diseases or persistent elevation of liver enzymes or bilirubin were applied in the pivotal clinical trials of [direct oral anticoagulants], considering the potential risk of liver injury and major bleeding. There is little evidence for patients with relatively mild liver disease or abnormalities on liver function tests.”
Lee and colleagues found that treatment with direct oral anticoagulants was associated with lower risk for ischemic stroke (HR = 0.548; 95% CI, 0.485-0.618) and intracranial hemorrhage (HR = 0.479; 95% CI, 0.394-0.581) compared with warfarin. Patients treated with direct oral anticoagulants also had lower risk for major bleeding (HR = 0.65; 95% CI, 0.575-0.736) and all-cause death (HR = 0.698; 95% CI, 0.636-0.765) compared with those treated with warfarin.
In other results, risk for the composite outcome of ischemic stroke, intracranial hemorrhage, hospitalization for gastrointestinal bleeding and all-cause death was also lower with direct oral anticoagulants compared with warfarin (HR = 0.61; 95% CI, 0.567-0.656).
While the study analyzed patients with liver disease, 13% of the population had significant active liver disease. This this group with severe disease, the HR for the composite outcome was 0.691 (95% CI, 0.577-0.827).
Choi told Cardiology Today these findings provide further insight for physicians who want to prescribe direct oral anticoagulants for stroke prevention in this population with AF and liver disease.
“This study could influence the choice of oral anticoagulants in patients with liver disease,” Choi told Cardiology Today. “We have shown that direct oral anticoagulants have better clinical outcomes compared with warfarin in patients with liver disease, mostly in mild liver disease. Patients with viral hepatitis and elevation of liver enzymes, who have significant active liver disease, also showed clinical benefits in stroke prevention and bleeding risk compared to warfarin. Although 2% of our study population have diagnosed liver cirrhosis, this study did not provide on the data in patients with an extremely high level of liver function and
Disclosures: Choi reports receiving grants from Bristol-Myers Squibb/Pfizer, Biosense Webster and Daiichi-Sankyo. Please see the study for all other authors’ relevant financial disclosures.