The Present and Future
JACC Review Topic of the Week
Oral Anticoagulation in Patients With Liver Disease

https://doi.org/10.1016/j.jacc.2018.03.023Get rights and content
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Abstract

Patients with liver disease are at increased risks of both thrombotic and bleeding complications. Many have atrial fibrillation (AF) or venous thromboembolism (VTE) necessitating oral anticoagulant agents (OACs). Recent evidence has contradicted the assumption that patients with liver disease are “auto-anticoagulated” and thus protected from thrombotic events. Warfarin and non–vitamin K–antagonist OACs have been shown to reduce thrombotic events safely in patients with either AF or VTE. However, patients with liver disease have largely been excluded from trials of OACs. Because all currently approved OACs undergo metabolism in the liver, hepatic dysfunction may cause increased bleeding. Thus, the optimal anticoagulation strategy for patients with AF or VTE who have liver disease remains unclear. This review discusses pharmacokinetic and clinical studies evaluating the efficacy and safety of OACs in patients with liver disease and provides a practical, clinically oriented approach to the management of OAC therapy in this population.

Key Words

anticoagulation
atrial fibrillation
bleeding
liver disease
thrombosis
venous thromboembolism

Abbreviations and Acronyms

AF
atrial fibrillation
EMA
European Medicines Agency
FDA
Food and Drug Administration
INR
international normalized ratio
NAFLD
nonalcoholic fatty liver disease
NOAC
non–vitamin K–antagonist oral anticoagulant agent
OAC
oral anticoagulant agent
PCC
prothrombin complex concentrate
PT
prothrombin time
PVT
portal vein thrombosis
VTE
venous thromboembolism

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Drs. Qamar and Vaduganathan are supported by the National Heart, Lung, and Blood Institute T32 post-doctoral training grant (T32HL007604). Dr. Greenberger has served on the hepatic clinical endpoint committee of the ENGAGE AF-TIMI 48 trial funded by Daiichi-Sankyo. Dr. Giugliano’s institution has received research grants from Daiichi-Sankyo to support the ENGAGE AF-TIMI 48 trial; honoraria for continuing medical education programs from Daiichi-Sankyo and the American College of Cardiology; and is a compensated consultant for Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi-Sankyo, Merck, Portola, and Pfizer.

Listen to this manuscript's audio summary by JACC Editor-in-Chief Dr. Valentin Fuster.