When Atrial Fibrillation Meets Alcoholic Liver Cirrhosis: Can Direct Oral Anticoagulants Bridge the Therapeutic Gap?

A significant clinical challenge is represented by the use of anticoagulants in patients with chronic liver diseases-such as metabolic steatohepatitis (MASH), metabolic associated steatotic liver disease (MASLD), and liver cirrhosis (LC). There is a well-established association between alcohol-related LC and atrial fibrillation (AF). These individuals often require anticoagulation, but treatment must carefully balance the heightened risks of both thrombosis and bleeding. Direct oral anticoagulants (DOACs) are recognized as effective and safe alternatives to warfarin, offering superior stroke prevention and a more favorable safety profile regarding major bleeding. They are generally considered safe for use in patients with LC classified as Child-Pugh A and B-excluding rivaroxaban-but are contraindicated in those with Child-Pugh C cirrhosis. DOACs also offer practical advantages, including convenience of administration, fewer drug interactions, and a high level of safety and efficacy. Comprehensive randomized controlled trials with well-defined cirrhosis stages and standardized anticoagulation protocols are essential to guide clinical decision-making. Until then, a multidisciplinary, individualized approach remains critical in managing patients with both AF and LC. The present review aims to explore the complex interplay between alcohol-related LC and the therapeutic use of direct oral anticoagulants (DOACs), particularly in the presence of cardiovascular risk factors such as atrial fibrillation, and the associated thrombotic complications.