Introduction: The presence of atrial fibrillation among patients with portal hepatopathy is one of the major causes of increased morbidity and mortality. The anti-coagulation strategy approach in these patients it is not specified in the current clinical guidelines and remains a particular therapeutic challenge due to the concomi-tant risks of both bleeding and thrombosis. Moreover, the absence of safety and efficacy data of oral anticoagulants in this particular category of patients implies a difficult approach, despite the release of novel oral anticoagulants (NOAC).

Case presentation: We report the case of a 73-year-old patient who presented in the emergency department for diffuse abdominal pain and paroxysmal nocturnal dyspnea. Pathological personal history includes congestive heart failure with preserved ejection fraction NYHA III class, mild aortic stenosis, severe mitral and tricuspid regurgitation, hypertensive and valvular car-diopathy. The initial clinical examination reveals irre-gular heart rhythm, arterial blood pressure of 110/70 Hg, diminished vesicular breath sound, SaO2 97% and normal abdominal examination. Blood tests re-vealed thrombocytopenia (54.000), hemoglobin level 10.9 g/dl, NT-pro BNP 19520 pg/ml, creatinine clea-rance 35ml/min, hepatic cytolysis syndrome (ASAT/ ALAT 115/64 U/L), total bilirubin 6,11 mg/dl, direct bilirubin 4,18 mg/l, LDH 395 U/L, INR 1,95. EKG: atrial fibrillation and left bundle branch block. Abdominal echography described hepatomegaly, distended hepatic veins and minimal ascites. Superior digestive endosco-py showed grade 1 esophageal varices and gastric an-tral erosions. Chest X-ray revealed medium left pleural effusion. Case particularity: Consisted in the evaluation of the decision to initiate oral anticoagulation in a patient with Child-Pugh class C liver cirrhosis and persistent atrial fibrillation with a CHA2D2-VASc score of 6 points and HAS-BLED score of 5 points. NOACs were excluded due to the contraindication of Child C class and predominant hepatic metabolism dependent on cytochro-me P450 (CYP) in different proportions for each drug. Antivitamin K anticoagulants were excluded due to difficulty adjusting doses in the presence of a spontane-ous INR, lack of validated target levels as well as CYP metabolic dependence. Warfarin, although controversial is a drug with several studies in liver cirrhosis, with lower risk of bleeding but currently unavailable in our country. Considering the exclusion of patients with severe liver damage from NOACs clinical trials, the absence of their existence for vitamin K antagonists and the concomitant risk of bleeding and thrombosis, we opted for HGMM anticoagulation in doses adjusted to renal clearance. The patient`s evolution was favorable, without ischemic complications or bleeding. Although oral anticoagulation options in patients with atrial fibrillation have diversified, clinical particularities and associated comorbidities sometimes make them risky and inadequate.