Cirrhotic patients on anticoagulation at increased risk of variceal haemorrhage
There appears to be a higher risk of bleeding among anticoagulated cirrhotic patients who have oesophageal varices, according to a recent study.
“We recommend that patients with cirrhosis and oesophageal varices who require anticoagulation have their varices managed carefully prior to initiation of anticoagulation,” researchers said.
The most common cause of cirrhosis among patients was nonalcoholic steatohepatitis (47 percent). Of these, 49 percent were classified as Child-Pugh class B, a mean model for end-stage liver disease score of 14 and Charlson comorbidity index of 7. [Am J Med 2019;132:758-766]
Fifty-six percent of patients were treated with anticoagulation for atrial fibrillation/atrial flutter, 57 percent with warfarin and 25 percent with concomitant use of antiplatelet therapy. Of these, 18 percent experienced bleeding, with upper gastrointestinal bleeding (53 percent) being the most common cause.
In the propensity-matched cohort, cirrhotic patients showed higher bleeding rates than controls who were matched for baseline characteristics. The presence of oesophageal varices among cirrhotic patients also put them at higher risk of clinically relevant bleeding, based on multivariable analysis.
“The occurrence of bleeding in noncirrhotic patients on anticoagulation can vary according to several factors, including indication for anticoagulation and type of anticoagulant used,” researchers said.
“[M]ost studies demonstrate a notably lower rate of bleeding in noncirrhotic patients on anticoagulation compared with the bleeding rates observed in our study and the existing current medical literature on cirrhotic patients,” they added. [Int J Cardiol 2015;179:279-287; Blood 2014;124:2450-2458]
The findings on cirrhotics was supported by those of an earlier study, which found that among 55 cirrhotic patients on anticoagulation with portal vein thrombosis, the bleeding rate was comparable to that reported in the current study (18.2 percent vs 18.4 percent). [Clin Gastroenterol Hepatol 2012;10:776-783]
In another study, 10 percent of cirrhotic patients on anticoagulation experienced bleeding. Half of these events were classified as moderate bleeds (nonlife-threatening but required transfusion or intervention). [Eur J Haematol 2017;98:393-397]
“We conclude that clinicians need to weigh the risk and benefit of initiating anticoagulation in cirrhotic patients and the presence of clinical decompensating events, particularly the presence of oesophageal varices,” researchers said. “We additionally suggest that clinicians undertake aggressive approaches to identify and treat oesophageal varices prior to initiation of anticoagulation.”
The current study performed a retrospective analysis of 320 cirrhotic patients treated with anticoagulation therapy from 15 July 2014 to 10 January 2018. Bivariate and multivariate analyses were carried out to identify risk factors for clinically relevant bleeding. Researchers also conducted a separate analysis using propensity score matching to compare bleeding rates between anticoagulated cirrhotic patients and noncirrhotic patients on anticoagulation.
“Large prospective trials examining anticoagulation therapy in cirrhotic patients for venous thromboembolism and portable vein thrombosis treatment or prevention are lacking,” researchers noted. “As such, prophylaxis or treatment of thrombosis in cirrhotic patients is often a result of extrapolation from therapeutic choices in noncirrhotic patients.” [N Engl J Med 2009;361:1139-1151; N Engl J Med 2013;368:699-708]