Atrial Fibrillation Is Highly Prevalent Yet Undertreated in Patients With Biopsy-proven Nonalcoholic Steatohepatitis

Maureen Whitsett; Jane Wilcox; Amy Yang; Lihui Zhao; Mary Rinella; Lisa B. VanWagner


Liver International. 2019;39(5):933-940. 

In This Article


Of 9108 patients with NAFLD/NASH by ICD-9 code alone, 514 had concomitant AF for an AF prevalence of 5.6%; the prevalence among those <65 years of age was 4.2%. We identified 215 patients with biopsy-proven NASH at our institution. Of the biopsy-proven NASH cohort, the overall prevalence of AF was 4.6% (n = 10) and the AF prevalence among those <65 years of age was 4.0% (n = 7 of 174). For comparison, we also identified 111 812 patients <65 years of age without NAFLD/NASH by ICD-9 code, of whom 3057 had a diagnosis of AF for an AF prevalence of 2.7% (Figure 1).

Figure 1.

Prevalence rates of atrial fibrillation in persons <65 y old according to disease status. General population estimate is derived from previously published data

The demographic characteristics of patients with biopsy-proven NASH stratified by AF status are shown in Table 1. Of the 10 patients with biopsy-proven NASH and AF, 7 had cirrhosis on biopsy (70.0%). Mean age of patients with biopsy-proven NASH was 53.7 ± 12.8 years and 37.1% were male. Patients with biopsy-proven NASH and AF were older (61.8 (standard deviation, 5.3 years) vs 53.1 (12.6) years) and had a higher prevalence of hypertension (81.8% vs 43.6%, P = 0.03), diabetes mellitus (81.8% vs 45.4%, P = 0.03), heart failure (54.5% vs 8.8%, P < 0.001) and cerebrovascular (27.3% vs 2%, P < 0.001) or vascular disease (54.5% vs 13.2%, P = 0.002), compared to those with NASH alone. Patients with biopsy-proven NASH and AF had more hospital visits (4.3 vs 2.0, P = 0.006) and longer hospital stays compared to those with NASH alone (11.1 vs 4.5 days, P = 0.002). Eight of the 10 patients had at least one hospitalization for cardiovascular-related events (Table 2). Two patients were hospitalized for gastrointestinal haemorrhage.

Documented therapy and stroke risk for the 10 biopsy-proven NASH with AF is shown in Table 3. Among this cohort, all patients had a CHA2DS2VASc score ≥2 indicating an annual stroke risk of 2.2% and thus an indication for anticoagulation.[22] Patients 1 and 7 received low dose aspirin therapy instead of anticoagulation therapy for secondary prevention of stroke; there is not a documented explanation for this undertreatment. Patients 9 and 10 received therapy with direct-acting oral anticoagulants, and three patients received therapy with warfarin. Patient 6 did not receive anticoagulant therapy because of a history of bleeding arteriovenous malformations in the gastrointestinal tract, and patient 8 had a history of bleeding esophageal varices. Patient 3 did not receive anticoagulation for unclear reasons. Thus, of the 10 patients in this cohort, 80% (n = 8) were eligible for guideline-appropriate anticoagulation and only 62.5% (n = 5) of eligible patients received anticoagulation therapy. Two patients were not receiving anticoagulation due to a history of recent bleeding.