TY - JOUR
T1 - Outcomes of Direct Oral Anticoagulants in Atrial Fibrillation Patients Across Different Body Mass Index Categories
AU - Barakat, Amr F.
AU - Jain, Sandeep
AU - Masri, Ahmad
AU - Alkukhun, Laith
AU - Senussi, Mourad
AU - Sezer, Ahmet
AU - Wang, Yisi
AU - Thoma, Floyd
AU - Bhonsale, Aditya
AU - Saba, Samir
AU - Mulukutla, Suresh
N1 - Funding Information:
Dr. Masri is supported by research grants from Pfizer and Akcea not related to the content of this paper. Dr. Mulukutla receives support for Heart and Vascular Institute Analytics from Boston Scientific not related to the content of the manuscript. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Publisher Copyright:
© 2021 American College of Cardiology Foundation
PY - 2021/5
Y1 - 2021/5
N2 - Objectives: This study sought to evaluate direct oral anticoagulant (DOAC) outcomes (vs. warfarin) in patients with atrial fibrillation (AF) across body mass index (BMI) categories, including ≥40 and <18.5 kg/m2. Background: Clinical trials have not systematically tested the fixed DOAC dosing in underweight and morbidly obese patients. Methods: We retrospectively included consecutive patients with nonvalvular AF with CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75, Diabetes, Stroke/transient ischemic attack/systemic thromboembolism, Vascular disease, Age 65-74, Sex) of ≥1 receiving OACs at our hospital system (2010–2018). Patients were categorized into groups 1 (underweight: BMI of <18.5 kg/m2), 2 (normal/overweight: BMI of 18.5 to <30 kg/m2), 3 (grade 1/2 obesity: BMI of 30 to <40 kg/m2), and 4 (grade 3 obesity: BMI of ≥40 kg/m2). We further classified patients by DOAC versus warfarin use. Outcomes were ischemic stroke, significant bleeding events (i.e., resulting in hospitalization), and mortality. Results: We included 36,094 patients with a mean age of 74 ± 11 years and CHA2DS2-VASc of 3.4 ± 1.5. Groups 1 through 4 included 455 (1.3%), 18,339 (50.8%), 13,376 (37.1%), and 3,924 (10.9%) patients, respectively. DOAC use ranged from 49% to 56%. At 3.8 follow-up years, with multivariable Cox regression, DOACs (vs. warfarin) were associated with lower risk of ischemic stroke, bleeding, and mortality across all BMI groups, with hazard ratios (HRs) of 0.73 (95% confidence interval [CI]: 0.63 to 0.85), 0.75 (95% CI: 0.64 to 0.87), 0.75 (95% CI: 0.65 to 0.88), and 0.75 (95% CI: 0.64 to 0.87) (p < 0.001 for all) for ischemic stroke; 0.42 (95% CI: 0.19 to 0.92), 0.41 (95% CI: 0.19 to 0.89), 0.45 (95% CI: 0.20 to 1.00), and 0.43 (95% CI: 0.20 to 0.94) (p < 0.05 for all) for bleeding; and 0.90 (95% CI: 0.68 to 1.19; p = 0.5), 0.70 (95% CI: 0.66 to 0.75; p < 0.0001), 0.65 (95% CI: 0.60 to 0.71; p < 0.0001), and 0.66 (95% CI: 0.56 to 0.77; p < 0.0001) for mortality, in groups 1 to 4, respectively. Conclusions: In patients with nonvalvular AF, DOACs compared to warfarin were associated with better safety and effectiveness across all BMI categories, including underweight and morbidly obese patients.
AB - Objectives: This study sought to evaluate direct oral anticoagulant (DOAC) outcomes (vs. warfarin) in patients with atrial fibrillation (AF) across body mass index (BMI) categories, including ≥40 and <18.5 kg/m2. Background: Clinical trials have not systematically tested the fixed DOAC dosing in underweight and morbidly obese patients. Methods: We retrospectively included consecutive patients with nonvalvular AF with CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75, Diabetes, Stroke/transient ischemic attack/systemic thromboembolism, Vascular disease, Age 65-74, Sex) of ≥1 receiving OACs at our hospital system (2010–2018). Patients were categorized into groups 1 (underweight: BMI of <18.5 kg/m2), 2 (normal/overweight: BMI of 18.5 to <30 kg/m2), 3 (grade 1/2 obesity: BMI of 30 to <40 kg/m2), and 4 (grade 3 obesity: BMI of ≥40 kg/m2). We further classified patients by DOAC versus warfarin use. Outcomes were ischemic stroke, significant bleeding events (i.e., resulting in hospitalization), and mortality. Results: We included 36,094 patients with a mean age of 74 ± 11 years and CHA2DS2-VASc of 3.4 ± 1.5. Groups 1 through 4 included 455 (1.3%), 18,339 (50.8%), 13,376 (37.1%), and 3,924 (10.9%) patients, respectively. DOAC use ranged from 49% to 56%. At 3.8 follow-up years, with multivariable Cox regression, DOACs (vs. warfarin) were associated with lower risk of ischemic stroke, bleeding, and mortality across all BMI groups, with hazard ratios (HRs) of 0.73 (95% confidence interval [CI]: 0.63 to 0.85), 0.75 (95% CI: 0.64 to 0.87), 0.75 (95% CI: 0.65 to 0.88), and 0.75 (95% CI: 0.64 to 0.87) (p < 0.001 for all) for ischemic stroke; 0.42 (95% CI: 0.19 to 0.92), 0.41 (95% CI: 0.19 to 0.89), 0.45 (95% CI: 0.20 to 1.00), and 0.43 (95% CI: 0.20 to 0.94) (p < 0.05 for all) for bleeding; and 0.90 (95% CI: 0.68 to 1.19; p = 0.5), 0.70 (95% CI: 0.66 to 0.75; p < 0.0001), 0.65 (95% CI: 0.60 to 0.71; p < 0.0001), and 0.66 (95% CI: 0.56 to 0.77; p < 0.0001) for mortality, in groups 1 to 4, respectively. Conclusions: In patients with nonvalvular AF, DOACs compared to warfarin were associated with better safety and effectiveness across all BMI categories, including underweight and morbidly obese patients.
KW - atrial fibrillation
KW - bleeding
KW - obesity
KW - oral anticoagulation
KW - stroke
KW - underweight
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U2 - 10.1016/j.jacep.2021.02.002
DO - 10.1016/j.jacep.2021.02.002
M3 - Article
C2 - 33812834
AN - SCOPUS:85104997824
VL - 7
SP - 649
EP - 658
JO - JACC: Clinical Electrophysiology
JF - JACC: Clinical Electrophysiology
SN - 2405-5018
IS - 5
ER -