Efficacy and safety of direct oral anticoagulant in morbidly obese patients with atrial fibrillation: systematic review and meta-analysis

Eur Heart J Cardiovasc Pharmacother. 2022 Jun 8;8(4):325-335. doi: 10.1093/ehjcvp/pvab026.

Abstract

Aims: We conducted a systematic review and meta-analysis on three outcomes. We assessed the efficacy and safety of direct oral anticoagulants (DOAC) compared to vitamin K antagonists (VKA) in morbidly obese patients with atrial fibrillation (AF). We compared the efficacy and safety of DOAC in obese patients and non-obese patients with AF. Finally, we updated the current knowledge of outcomes of AF patients with obesity compared with normal-weight patients regardless of anticoagulation type.

Methods and results: Using PubMed and Embase, we searched for literature published from inception to August 2020 for studies conducted in morbidly obese patients with AF who used DOACs and/or VKA for stroke or systemic embolism (stroke/SE) prevention that report efficacy and/or safety data. GRADE assessment was performed to determine the quality of the meta-analysis results. Direct oral anticoagulant was not statistically different from VKA in reducing stroke/SE with relative risk (RR) of 0.85 [95% confidence interval (CI): 0.56-1.29; very low certainty evidence]. Major bleeding risk was lower in the DOAC groups with RR of 0.62 (95% CI: 0.48-0.80; low certainty evidence). Obese patients with AF who used DOACs had lower risk of stroke/SE and similar major bleeding risk compared to non-obese patients with RR of 0.77 (95% CI: 0.70-0.84; low certainty evidence) and 1.02 (95% CI: 0.94-1.09; low certainty evidence), respectively. Obese patients with AF who used any type of anticoagulant had lower risk of stroke/SE compared to normal-weight patients with RR of 0.62 (95% CI: 0.57-0.69; low certainty evidence).

Conclusion: The use of DOACs in morbidly obese patients may be reasonable if needed, and more dedicated studies are needed to make a more robust recommendation.

Keywords: Atrial fibrillation; Direct oral anticoagulant; Factor Xa inhibitor; Morbid obesity.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Administration, Oral
  • Anticoagulants / adverse effects
  • Atrial Fibrillation* / complications
  • Atrial Fibrillation* / diagnosis
  • Atrial Fibrillation* / drug therapy
  • Embolism*
  • Fibrinolytic Agents / therapeutic use
  • Hemorrhage / chemically induced
  • Humans
  • Obesity, Morbid* / chemically induced
  • Obesity, Morbid* / complications
  • Obesity, Morbid* / diagnosis
  • Stroke* / diagnosis
  • Stroke* / epidemiology
  • Stroke* / etiology

Substances

  • Anticoagulants
  • Fibrinolytic Agents