Atrial fibrillation in patients with liver disease: Recent advances.

Abstract

Atrial fibrillation is associated with significant morbidity and mortality, and its incidence is increasing globally. The primary complication of atrial fibrillation is ischemic stroke, the risk of which 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 pathophysiologic changes of the coagulation cascade and as a result, the 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 internationalized normalized ratio (INR) elevation, changes in hepatic drug elimination, and thrombocytopenia. We review the contemporary 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.