Anticoagulation for Stroke Prevention in Atrial Fibrillation and Treatment of Venous Thromboembolism and Portal Vein Thrombosis in Cirrhosis: Guidance from the SSC of the ISTH
Stephanie Carlin 1, Adam Cuker 2, Alexander Gatt 3, Nicolas Gendron 4, Virginia Hernandez-Gea 5, Karina Meijer 6, Deborah M. Siegal 7, Simon Stanworth 8, Ton Lisman 9 ∗, Lara N. Roberts 10 ∗
1-Department of Medicine, McMaster University, Hamilton, Ontario, Canada
2-Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
3-Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
4-University Paris Cité, Innovative Therapies in Haemostasis, INSERM, 75006 Paris, France, Hematology Department, Assistance Publique Hôpitaux de Paris. Centre-Université de Paris (APHP,CUP), 20 rue Leblanc, 75015, Paris, France
5-Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, IDIBAPS, University of Barcelona, Red de Enfermedades Hepáticas y Digestivas (CIBEREHD). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
6-Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
7-Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
8-Transfusion Medicine, NHS Blood and Transplant, Oxford, UK; Department of Haematology, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre (Haematology), Oxford, UK
9-Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
10-King’s Thrombosis Centre, Department of Haematological Medicine, King’s College Hospital, London, UK
Abstract
Whilst advanced liver disease was previously considered to be an acquired bleeding disorder, there is increasing recognition of an associated prothrombotic state with patients being at higher risk of atrial fibrillation (AF) and stroke and venous thromboembolism including portal vein thrombosis (PVT). We review the available literature on epidemiology, pathophysiology and risk factors and provide guidance on anticoagulant management of these conditions in adults with cirrhosis. In patients with Child-Pugh A or B cirrhosis and AF, we recommend anticoagulation with standard dose direct oral anticoagulants (DOACs) in accordance with cardiology guideline recommendations for patients without liver disease. In those with Child-Pugh C cirrhosis, there is inadequate evidence with respect to the benefit and risk of anticoagulation for AF. For patients with cirrhosis and acute deep vein thrombosis or pulmonary embolism, we recommend anticoagulation and suggest use of either a DOAC or low molecular weight heparin/vitamin K antagonist. We recommend anticoagulation for patients with cirrhosis and symptomatic PVT. We suggest anticoagulation for those with asymptomatic, progressing PVT and recommend continuing extended anticoagulation for liver transplant candidates with PVT.