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

J Thromb Haemost. 2024 Sep;22(9):2653-2669. doi: 10.1016/j.jtha.2024.05.023. Epub 2024 May 31.

Abstract

While 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 (VTE) 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 stroke prevention in AF. In 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 (LMWH)/vitamin K antagonist (VKA) in Child-Pugh A or B cirrhosis and LMWH alone (or as a bridge to VKA in patients with a normal baseline international normalized ratio) in Child-Pugh C cirrhosis. 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.

Keywords: anticoagulation; atrial fibrillation; liver cirrhosis; portal vein; venous thrombosis.

Publication types

  • Review
  • Practice Guideline

MeSH terms

  • Anticoagulants* / administration & dosage
  • Anticoagulants* / adverse effects
  • Anticoagulants* / therapeutic use
  • Atrial Fibrillation* / complications
  • Atrial Fibrillation* / diagnosis
  • Atrial Fibrillation* / drug therapy
  • Blood Coagulation / drug effects
  • Hemorrhage / chemically induced
  • Heparin, Low-Molecular-Weight / administration & dosage
  • Heparin, Low-Molecular-Weight / therapeutic use
  • Humans
  • Liver Cirrhosis* / complications
  • Liver Cirrhosis* / drug therapy
  • Portal Vein*
  • Risk Assessment
  • Risk Factors
  • Stroke* / etiology
  • Stroke* / prevention & control
  • Treatment Outcome
  • Venous Thromboembolism* / diagnosis
  • Venous Thromboembolism* / drug therapy
  • Venous Thromboembolism* / etiology
  • Venous Thromboembolism* / prevention & control
  • Venous Thrombosis* / diagnosis
  • Venous Thrombosis* / drug therapy
  • Venous Thrombosis* / etiology
  • Venous Thrombosis* / prevention & control

Substances

  • Anticoagulants
  • Heparin, Low-Molecular-Weight