Efficacy and Safety of DOACs in Morbidly Obese Patients

Quick Takes

  • The use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (AF) weighing ≥120 kg was not associated with an increased risk of thromboembolic events or bleeding compared to those patients weighing 60-120 kg.
  • The results of this study add to the growing body of literature demonstrating that DOACs are a reasonable alternative for patients with non-valvular AF who are obese, specifically those with a body weight exceeding 120 kg.

Study Questions:

Are DOACs safe and effective in obese patients weighing ≥120 kg?


This was a single-center retrospective study in patients weighing ≥120 kg with nonvalvular AF who were taking apixaban, rivaroxaban, or dabigatran between January 1, 2011 and September 30, 2018. A total of 348 patients >18 years of age were included and were matched to patients weighing 60-120 kg based on age, sex, ethnicity, and prescribed oral anticoagulant. Additional baseline characteristics collected included creatinine clearance, weight, BMI, and CHA2DS2-VASc score. Patients were followed for 1 year after their initial encounter. The primary outcome was the incidence of stroke, deep vein thrombosis, pulmonary embolus, or myocardial infarction. The primary safety outcome was a composite of the incidence of major or clinically relevant non-major bleeding as defined by the International Society of Thrombosis and Hemostasis.


The median weight and BMI for patients included in the ≥120 kg group were 132.1 kg and 41 kg/m2, respectively, while the median weight and BMI in the <120kg group was 93 kg and 29.4 kg/m2, respectively. The median age was 63 years with 78% being male. Approximately 80% were Caucasian. Apixaban was the most commonly prescribed anticoagulant at 55%, with rivaroxaban being the next most frequent agent at 27%, and dabigatran at 19%. The primary endpoint occurred in 2.5% of patients in the ≥120 kg group versus 3.1% in the <120 kg group (p = 0.632). The incidence of the composite safety outcome occurred in 5.3% in patients in the ≥120 kg group compared to 6.6% in the <120 kg group (p = 0.503).


This retrospective review demonstrated that apixaban, rivaroxaban, and dabigatran are safe and effective in patients with nonvalvular AF weighing ≥120 kg.


Several retrospective studies have been published that have demonstrated similar findings in the obese population. This was one of the largest retrospective studies conducted to date. Of note, the occurrence of the primary endpoint did not correlate to extreme body weight as the median weight of the primary outcome occurrence was 128.3 kg, while the range of patients enrolled was 126-143.4 kg. These results add to the growing body of literature for the use of DOACs in obese patients (≥120 kg) with nonvalvular AF. However, the number of patients with severe obesity (BMI >50 kg/m2 or weight >150 kg) were underrepresented and additional evaluation is likely needed in this patient population.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiovascular Care Team

Keywords: Anticoagulants, Obesity, Arrhythmias, Cardiac, Atrial Fibrillation, Care Team

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