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Comparative Effectiveness and Safety of Direct Oral Anticoagulants in Obese Patients with Atrial Fibrillation

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Abstract

Background

Unlike warfarin direct oral anticoagulants (DOACs) are administered in fixed doses, which raises concerns of its effectiveness on larger patients. Data from randomized trials are limited on the safety and efficacy of DOACs in morbidly obese individuals with atrial fibrillation (AF).

Methods

We analyzed a cohort of obese (≥ 120 kg) and morbidly obese (BMI > 40 kg/m2) patients from the Veterans Health Administration system with AF who initiated apixaban, rivaroxaban, dabigatran, or warfarin between years 2012 and 2018. We used inverse probability of treatment weighting (IPTW) and Cox proportional hazards regression models to evaluate the relative hazard of death, myocardial infarction (MI), ischemic stroke, heart failure (HF), and bleeding events between oral anticoagulant (OAC) groups while censoring for medication cessation.

Results

We identified 6052 obese patients on apixaban, 4233 on dabigatran, 4309 on rivaroxaban, and 13,417 on warfarin (mean age 66.7 years, 91% males, 80.4% whites). At baseline patients on apixaban had the lowest glomerular filtration rate and highest rates of previous stroke and MI compared to other OACs. Among patients with weight ≥ 120 kg and those with BMI > 40 kg/m2, all DOACs were associated with lower risk of any hemorrhage, hemorrhagic stroke, and gastrointestinal (GI) bleeding. Patients with BMI > 40 kg/m2 treated with DOACs had similar ischemic stroke risk with those on warfarin.

Conclusions

In this large cohort of obese Veterans Health Administration system patients, the use of DOACs resulted in lower hemorrhagic complications than warfarin while maintaining efficacy on ischemic stroke prevention.

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Authors and Affiliations

  1. Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa College of Medicine, 200 Hawkins Drive, Iowa City, IA, 52242, USA

    Alexandros Briasoulis, Amgad Mentias, Alexander Mazur & Paulino Alvarez

  2. National Kapodistrian University of Athens, Medical School, Athens, Greece

    Alexandros Briasoulis, Amgad Mentias, Alexander Mazur & Paulino Alvarez

  3. Departments of Neurology and Neurosurgery, Carver College of Medicine, and Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA

    Enrique C. Leira

  4. Division of General Medicine, Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, IA, USA

    Mary S. Vaughan Sarrazin

  5. Comprehensive Access and Delivery Research and Evaluation Center, Iowa City VA Medical Center, Iowa City, IA, USA

    Mary S. Vaughan Sarrazin

Authors
  1. Alexandros Briasoulis
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  2. Amgad Mentias
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  3. Alexander Mazur
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  4. Paulino Alvarez
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  5. Enrique C. Leira
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  6. Mary S. Vaughan Sarrazin
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Contributions

Briasoulis designed and wrote manuscript, supervised others, prepared the revisions, and participated in analysis. Mentias participated in analysis and wrote part of the manuscript. Mazur provided feedback on DOACs and atrial fibrillation. Alvarez participated in preparation of database and manuscript writing. Leira provided feedback on stroke and AF. Sarrazin provided access to the database and participated in the analysis.

Corresponding author

Correspondence to Alexandros Briasoulis.

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The authors declare that they have no conflict of interest.

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This article does not contain any studies with human participants or animals performed by any of the authors.

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Informed consent was not required as the data were de-identified and the study was deemed IRB-exempt by the University of Iowa IRB.

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Briasoulis, A., Mentias, A., Mazur, A. et al. Comparative Effectiveness and Safety of Direct Oral Anticoagulants in Obese Patients with Atrial Fibrillation. Cardiovasc Drugs Ther 35, 261–272 (2021). https://doi.org/10.1007/s10557-020-07126-2

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  • DOI: https://doi.org/10.1007/s10557-020-07126-2

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