DOACs reduce risk for new-onset portal hypertension in patients with cirrhosis and atrial fibrillation: A retrospective cohort study

Patients with liver cirrhosis and atrial fibrillation (AF) pose a therapeutic challenge due to the conflicting risks of thrombosis and bleeding. The role of direct oral anticoagulants (DOACs) in this population remains uncertain. This study aims to evaluate the impact of anticoagulation therapy on new-onset portal hypertension and related complications in cirrhotic patients with AF. A retrospective cohort study was conducted in 502 hospitalized patients with cirrhosis and AF at Beijing Ditan Hospital (2010-2019). Clinical data, risk scores, and liver severity indices (Child-Pugh, Model for End-Stage Liver Disease) were collected. Propensity score matching was applied to minimize confounding. Primary endpoints were new-onset portal hypertension and all-cause mortality; secondary endpoints included gastrointestinal bleeding and thromboembolic events. Among 502 patients, 50 received oral anticoagulation. Anticoagulation was associated with a significantly lower risk of new-onset portal hypertension (P < .001) and gastrointestinal bleeding (P < .005) without increasing mortality (P < .003). After propensity score matching (n = 233), anticoagulation continued to reduce portal hypertension (P < .026) and gastrointestinal bleeding (P < .025), with no significant effect on mortality. Kaplan-Meier analysis confirmed improved survival in the anticoagulation group (P < .002). In cirrhotic patients with AF, anticoagulation, particularly direct oral anticoagulants, may lower the risk of portal hypertension and gastrointestinal bleeding without increasing mortality. Prospective studies are warranted to confirm these findings and guide clinical decision-making.