Outcomes of Direct Oral Anticoagulants in Atrial Fibrillation Patients Across Different Body Mass Index Categories

Fusco

et al. 2021

JCM

The use of the direct oral anticoagulants dabigatran, rivaroxaban, apixaban and edoxaban (DOACs) offers some major advantages over warfarin and other vitamin K antagonists (VKAs). One advantage is the possibility to use a fixed dose in normal-weight patients, overweight patients and patients with obesity. However, the “one size fits all” strategy raised a concern regarding the possibility to undertreat patients with a high body mass index. No randomized controlled trials (RCTs) have ever compared VKAs and DOACs in this population. We analyzed data from the literature on DOAC pharmacokinetics and pharmacodynamics, results from the four pivotal phase III trials on non-valvular atrial fibrillation, retrospective observational studies and metanalyses. While we are aware of the limitation imposed by the absence of specific RCTs, we propose the position of the Italian Association of Hospital Cardiologists (ANMCO) on the use of DOACs in patients with obesity based on the existing evidence.

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…A different number of studies have been performed for each DOAC. Rivaroxaban and apixaban are the most studied [ 70 ].…”

Section: Discussionmentioning

confidence: 99%

Section: Recent Large Studies On Doacs In Patients With Obesitymentioning

confidence: 99%

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Direct Oral Anticoagulants in Patients with Obesity and Atrial Fibrillation: Position Paper of Italian National Association of Hospital Cardiologists (ANMCO)

Fusco

et al. 2021

JCM

“…In fact, evidence indicates that, among patients with AF, underweight individuals are a special population that need additional care. For example, among patients with AF taking direct oral anticoagulants (DOACs), being underweight was associated with an increased risk of major bleeding, thromboembolism, and death [13][14][15]. However, the risks associated with being underweight are rather difficult to address, especially as a relatively small proportion of Caucasians are underweight compared to Asians.…”

Section: Introductionmentioning

confidence: 99%

Underweight is a major risk factor for atrial fibrillation in Asian people with type 2 diabetes mellitus

Hsu

Yang

Chuang

et al. 2021

Cardiovasc Diabetol

Background Atrial fibrillation (AF) is prevalent in patients with type 2 diabetes mellitus (T2DM). Obesity commonly accompanies T2DM, and increases the risk of AF. However, the dose-relationship between body mass index (BMI) and AF risk has seldom been studied in patients with diabetes. Methods This cohort study utilized a database from National Taiwan University Hospital, a tertiary medical center in Taiwan. Between 2014 and 2019, 64,339 adult patients with T2DM were enrolled for analysis. BMI was measured and categorized as underweight (BMI < 18.5), normal (18.5 ≤ BMI < 24), overweight (24 ≤ BMI < 27), obesity class 1 (27 ≤ BMI < 30), obesity class 2 (30 ≤ BMI < 35), or obesity class 3 (BMI ≥ 35). Multivariate Cox regression and spline regression models were employed to estimate the relationship between BMI and the risk of AF in patients with T2DM. Results The incidence of AF was 1.97 per 1000 person-years (median follow-up, 70.7 months). In multivariate Cox regression, using normal BMI as the reference group, underweight (HR 1.52, 95% CI 1.25–1.87, p < 0.001) was associated with a significantly higher risk of AF, while overweight was associated with significantly reduced risk of AF (HR 0.82, 95% CI 0.73–0.89, p < 0.001). Kaplan–Meier analysis showed AF risk was highest in the underweight group, followed by obesity class 3, while the overweight group had the lowest incidence of AF (log-rank test, p < 0.001). The cubic restrictive spline model revealed a “J-shaped” or “L-shaped” relationship between BMI and AF risk. Conclusions Underweight status confers the highest AF risk in Asian patients with T2DM.

Apixaban and rivaroxaban use for atrial fibrillation in patients with obesity and BMI ≥50 kg/m²

et al. 2021

Background: Apixaban and rivaroxaban are increasingly used for thromboembolism prophylaxis in patients with non-valvular atrial fibrillation (NVAF) and commonly in patients with obesity and body mass index (BMI) ≥50 kg/m 2 despite the limited data.Objectives: This study aimed to establish the effectiveness and safety of apixaban and rivaroxaban in patients with NVAF and BMI ≥50 kg/m 2 .Methods: A single health-system, retrospective cohort study evaluated the effectiveness and safety of apixaban and rivaroxaban initiated in adult patients (≥18 years of age) with BMI ≥50 kg/m 2 and NVAF. Outcomes of ischemic stroke, systemic embolic events, and bleeding were compared to a cohort of patients with BMI 18 to 30 kg/m 2 .Results: After 1619 patient-years worth of follow-up in 595 patients, the primary endpoint of incidence of ischemic stroke was numerically similar in both groups, 1.3 per 100 patient-years in the BMI ≥50 kg/m 2 group, compared to 2.0 per 100 patientyears in the BMI <30 kg/m 2 group (RR 0.65, 95% CI 0.38-1.82, p = 0.544). Incidence of major bleeding and clinically relevant non-major bleeding was also numerically similar between the two groups.Conclusions: This study demonstrated that apixaban and rivaroxaban in patients with a BMI ≥50 kg/m 2 for treatment of NVAF may be safe and effective at preventing thromboembolic events and had no increased risk of bleeding. Although, findings should be interpreted with caution and confirmed with additional studies. This study contributes to the growing body of evidence that direct oral anticoagulants (DOACs) may be effective and safe to use for the treatment of NVAF in patients with BMI ≥50 kg/m 2 .