Internal Medicine Unit, Pavullo Hospital, Azienda USL, Modena, Italy.
Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy.
Adv Ther. 2020 May;37(5):1910-1932. doi: 10.1007/s12325-020-01307-z. Epub 2020 Apr 13.
Atrial fibrillation (AF) and venous thromboembolism (VTE) are highly prevalent and relevant healthcare issues. Direct oral anticoagulants (DOACs) are now the first-choice for anticoagulant treatment of these conditions displaying a better efficacy/safety profile than vitamin-K antagonists, mainly due to significantly reduced risk of major bleeding, especially of intracranial haemorrhage. Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in developed countries showing a continuously growing prevalence. Nonalcoholic steatohepatitis (NASH), its evolutive form, will be the leading cause for liver transplantation by 2020. NAFLD is independently associated with an increased risk of abnormalities of cardiac structure and function, including cardiac rhythm disorders (mainly AF). Moreover, data suggest an increased risk of unprovoked VTE associated with NAFLD/NASH. Therefore, a growing number of patients with chronic liver disease (CLD) will be candidate for anticoagulant therapy in the near future. Cirrhosis of any etiology is characterized by an unstable thrombosis/bleeding haemostatic balance, making anticoagulant therapy particularly challenging in this condition. Given that patients with significant active liver disease and cirrhosis were excluded from all pivotal randomized controlled trials on DOACs, this comprehensive review aims at critically discussing real-world evidence, including the latest population studies, regarding the use of DOACs in patients with CLD/cirrhosis.
心房颤动（AF）和静脉血栓栓塞症（VTE）是高度流行且相关的医疗保健问题。直接口服抗凝剂（DOAC）现在是这些疾病抗凝治疗的首选，其疗效/安全性优于维生素 K 拮抗剂，主要是因为大出血风险，尤其是颅内出血风险显著降低。非酒精性脂肪性肝病（NAFLD）是发达国家最常见的肝脏疾病，其患病率持续上升。非酒精性脂肪性肝炎（NASH）是其进行性形式，到 2020 年将成为肝移植的主要原因。NAFLD 与心脏结构和功能异常的风险增加独立相关，包括心律失常（主要是 AF）。此外，数据表明，NAFLD/NASH 与未诱发的 VTE 风险增加相关。因此，在不久的将来，越来越多的慢性肝病（CLD）患者将成为抗凝治疗的候选者。任何病因的肝硬化都表现出不稳定的血栓形成/出血止血平衡，使抗凝治疗在这种情况下特别具有挑战性。鉴于所有关键随机对照试验均排除了有明显活动性肝病和肝硬化的患者，因此，这篇全面综述旨在批判性地讨论有关 DOAC 在 CLD/肝硬化患者中的使用的真实世界证据，包括最新的人群研究。
