Effectiveness and safety of direct oral anticoagulants versus vitamin K antagonists in atrial fibrillation patients with liver disease: a systematic review and meta-analysis

作者：Qiang Zhou, Xiang Liu, Shuyu Liu, Zhi‐Chun Gu, Yanzi Wu, Yuansu Yang, Yingying Tao, Meng Wei · 发表于：Frontiers in Pharmacology · 年份：2025 · DOI：10.3389/fphar.2025.1620394 · 被引用次数：7 · 研究领域：Atrial Fibrillation Management and Outcomes、Liver Disease and Transplantation、Vitamin K Research Studies

Introduction: Patients with atrial fibrillation (AF) and liver disease, particularly cirrhosis, are frequently excluded from anticoagulation trials, leaving the optimal therapeutic strategy uncertain. Methods: This study aimed to compare the effectiveness and safety of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with AF and liver disease. We systematically searched the PubMed, Cochrane Library, Medline, and Embase databases for relevant studies published up to November 2024. Results: Fourteen studies, involving 44,848 participants, were included. Compared to VKAs, DOACs were associated with significantly lower risks of major bleeding (risk ratio [RR]: 0.64, 95% confidence interval [CI]: 0.55-0.75; P < 0.0001), intracranial bleeding (RR: 0.43, 95% CI: 0.33-0.56; P < 0.0001), gastrointestinal (GI) bleeding (RR: 0.72, 95% CI: 0.59-0.89; P = 0.002), and all-cause mortality (RR: 0.83, 95% CI: 0.70-0.98; P = 0.03). No significant difference was observed in ischemic stroke/systemic embolism (RR: 0.77, 95% CI: 0.52-1.13; P = 0.19). In patients with cirrhosis, DOACs were similarly superior for major bleeding, GI bleeding, and intracranial bleeding. Subgroup analyses revealed that apixaban demonstrated a more favorable safety profile than rivaroxaban in patients with liver disease, whereas both agents showed comparable effectiveness and safety in cirrhotic patients. Conclusion: DOACs are safer and equally effective alternatives to VKAs in patients wi...