Review Article

Diagnosis, Pathophysiology and Management of Atrial Fibrillation in Cirrhosis and Portal Hypertension

Bert Vandenberk; Mario H. Altieri; Hongqun Liu; Satish R. Raj; Samuel S. Lee


Aliment Pharmacol Ther. 2023;57(3):290-303. 

In This Article

Abstract and Introduction


Background: Atrial fibrillation (AF) is the most common arrhythmia and its management in cirrhosis can be challenging due to the altered hepatic metabolism of medications and increased risk of bleeding.

Aims: To provide a comprehensive overview of the diagnosis, pathophysiology and management of AF in patients with cirrhosis from both a cardiology and a hepatology perspective.

Methods: An extensive literature search was performed using the terms 'atrial fibrillation' and 'cirrhosis'. Guideline documents and consensus statements were explored.

Results: The prevalence of AF in patients with cirrhosis ranges between 6.6% and 14.2%, while the incidence of new-onset AF in the post-operative period after liver transplant ranged between 6.8% and 10.2%. AF in patients with cirrhosis is associated with adverse outcomes in both pre-transplant and post-transplant settings, including an increased risk of stroke when compared to the general population. We review the pathogenesis of AF in general and in cirrhosis. This review also provides guidance on the management of AF, including the use of anticoagulation and rate versus rhythm control. In the absence of strict contraindications, all patients with cirrhosis and AF should be anticoagulated. The use of DOACs is preferred over vitamin K antagonists. In patients with a high bleeding risk, a DOAC with an approved antidote may be preferred.

Conclusions: Atrial fibrillation is increased in patients with cirrhosis. AF management requires careful consideration of treatment options. Since patients with cirrhosis were excluded from all major randomised clinical trials, dedicated research on the pathophysiology and management of AF in cirrhosis is needed.


Cirrhosis is associated with a host of cardiovascular anomalies, including cirrhotic cardiomyopathy[1] and electrophysiologic abnormalities, such as QT prolongation[2] and arrhythmias. Atrial fibrillation (AF) is the most common arrhythmia and is associated with an increased risk of heart failure, stroke, and both all-cause and cardiovascular mortality.[3] While in some reports a potential protective effect of cirrhosis on the risk of AF has been suggested,[4] the majority of studies report an increased risk of AF.[5–7] The interaction between AF and cirrhosis may potentially further increase the risk of cardiovascular events in patients with cirrhosis.[8] AF management in cirrhosis can be challenging, for example due to altered hepatic metabolism of anti-arrhythmic drugs or increased risk of bleeding of oesophageal and gastric varices. We performed an extensive literature search on PubMed using the terms 'atrial fibrillation', 'cirrhosis', and additional terms such as 'anticoagulation' and 'pathophysiology'. Further, guideline documents and consensus statements of different organisations were explored, including snowballing to capture alternative resources with different phrasings. This review provides a comprehensive overview of the diagnosis, pathophysiology, and management of AF in patients with cirrhosis from a cardiology and hepatology perspective.