DOACs in Underweight and Obese Atrial Fibrillation Patients

Jun 22, 2021
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Authors:
Barakat AF, Jain S, Masri A, et al.
Citation:
Outcomes of Direct Oral Anticoagulants in Atrial Fibrillation Patients Across Different Body Mass Index Categories. JACC Clin Electrophysiol 2021;7:649-658.
Summary By:
Geoffrey D. Barnes, MD, MSc, FACC

Quick Takes

  • Patients with nonvalvular AF experienced lower stroke, bleeding, and mortality with DOAC versus warfarin therapy.
  • Patients at the extremes of body weight (BMI <18.5 and ≥40 kg/m2) had better safety and efficacy with DOAC as compared to warfarin.

Study Questions:

What are the outcomes for patients prescribed warfarin or direct oral anticoagulants (DOACs) across body mass index (BMI) categories?

Methods:

The authors retrospectively included consecutive patients with nonvalvular atrial fibrillation (AF) with CHA2DS2-VASc score ≥1 who were given oral anticoagulants (OACs) at a multisite hospital system (2010-2018). Patients were categorized by BMI category (underweight [<18.5 kg/m2], normal/overweight [18.5-30 kg/m2], grade 1/2 obesity [30-<40 kg/m2], grade 3 obesity [≥40 kg/m2]). Outcomes assessed included ischemic stroke, significant bleeding events, and mortality using multivariable Cox analysis.

Results:

Among 36,094 patients prescribed OAC for AF, the mean age was 74 ± 11 years and CHA2DS2-VASc score 3.4 ± 1.5, and included 3,924 (10.9%) patients with BMI ≥40. At 3.8 years of follow-up, DOAC use (as compared to warfarin) was associated with lower adjusted risk of ischemic stroke, bleeding, and mortality across all BMI groups.

Conclusions:

The authors concluded that patients with nonvalvular AF experienced better safety and effectiveness across all BMI categories when treated with DOAC as compared to warfarin.

Perspective:

While numerous meta-analyses and real-world studies have confirmed the safety and efficacy of DOACs versus warfarin for patients with AF, concerns have remained about those at the extremes of body weight. This study provides reassuring data for patients with BMI <18.5 and ≥40 kg/m2 who were treated with DOAC medications. Despite concerns of residual confounding in any observational data, this study does employ robust methods and relatively large sample size. Clinicians should be reassured that DOAC therapy is likely effective and safe for patients with AF at extremes of body weight. If there remain concerns, anti-Xa levels can be measured to ensure adequate therapeutic levels are achieved following DOAC administration.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Body Mass Index, Body Weight, Brain Ischemia, Geriatrics, Hemorrhage, Obesity, Overweight, Secondary Prevention, Stroke, Thinness, Vascular Diseases, Warfarin


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