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Efficacy and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients with Atrial Fibrillation Across BMI Categories: A Systematic Review and Meta-Analysis

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Abstract

Objectives

Concerns have arisen recently over the relationship between body mass index (BMI) and outcomes in atrial fibrillation (AF) patients with direct oral anticoagulants (DOACs). This meta-analysis aimed to explore if there is an “obesity paradox” in anticoagulated AF patients, and compare the treatment effects between DOACs and warfarin in AF patients across BMI categories.

Methods

We systematically searched the PubMed and Embase databases until February 26, 2019 for relevant studies. Risk ratios (RRs) with 95% confidence intervals (CIs) were extracted and pooled by a random-effects model.

Results

A total of nine studies were included. Compared with normal weight, underweight was associated with an increased risk of stroke or systemic embolism (SSE) (RR 1.98, 95% CI 1.19–3.28), whereas either overweight or obesity was related with reduced rates of SSE (overweight: RR 0.81, 95% CI 0.71–0.91; obesity: RR 0.69, 95% CI 0.61–0.78) and all-cause death (overweight: RR 0.73, 95% CI 0.64–0.83; obesity: RR 0.72, 95% CI 0.66–0.79). Compared with patients receiving warfarin, patients receiving DOACs who were underweight, normal weight or overweight all had decreased risks of SSE (underweight: RR 0.61, 95% CI 0.46–0.80; normal weight: RR 0.72, 95% CI 0.58–0.91; overweight: RR 0.87, 95% CI 0.76–0.99) and major bleeding (underweight: RR 0.67, 95% CI 0.55–0.81; normal weight: RR 0.72, 95% CI 0.58–0.90; overweight: RR 0.83, 95% CI 0.71–0.96), while obese DOAC users were at no higher risks for SSE and major bleeding.

Conclusions

There may be an obesity paradox in anticoagulated patients with AF. DOACs have better efficacy and safety profiles than warfarin in underweight, normal weight and overweight patients, and are not inferior to warfarin in obese patients.

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Authors and Affiliations

  1. Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China

    Yue Zhou

  2. Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China

    Jianyong Ma

  3. Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, Guangdong, China

    Wengen Zhu

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  1. Yue Zhou
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Correspondence to Wengen Zhu.

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Y-Z, JY-M and WG-Z declare that they have no potential conflicts of interest that might be relevant to the contents of this article.

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Yue Zhou and Jianyong Ma have co-first authorship.

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Zhou, Y., Ma, J. & Zhu, W. Efficacy and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients with Atrial Fibrillation Across BMI Categories: A Systematic Review and Meta-Analysis. Am J Cardiovasc Drugs 20, 51–60 (2020). https://doi.org/10.1007/s40256-019-00362-4

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  • DOI: https://doi.org/10.1007/s40256-019-00362-4

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