Real-world studies have evaluated the use of anticoagulants in obese patients with
nonvalvular atrial fibrillation (NVAF), but they have been limited by sample size
or the use of diagnosis codes on claims to define obesity. This retrospective study
used body weight data of ≥100 kg or a body mass index of ≥30 kg/m2 to identify elderly (aged ≥65 years) NVAF patients with obesity in dually enrolled
Veterans Affairs and fee-for-service Medicare patients. It evaluated the risk of stroke/systemic
embolism (SE) and major bleeding (MB) in patients that initiated apixaban versus warfarin.
Stabilized inverse probability treatment weighting was used to balance the baseline
characteristics between patients prescribed apixaban and warfarin in obese patients.
Cox models were used to evaluate the relative risk of stroke/SE and MB. Overall, 35.9%
(n = 26,522) of the NVAF population were obese, of which 13,604 apixaban and 12,918
warfarin patients were included. After inverse probability treatment weighting, patient
characteristics were balanced. The mean age was 75 years, the mean CHA2DS2-VASc score (Congestive Heart Failure, Hypertension, Age ≥75 [Doubled], Diabetes Mellitus,
Prior Stroke or Transient Ischemic Attack [Doubled], Vascular Disease, Age 65–74,
Female) was 3.8, the mean HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke,
Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly)
Score was ∼2.6, and >98% of patients were males. Obese apixaban patients were associated
with a similar risk of stroke/SE (hazard ratio: 0.82; 95% confidence interval: 0.66
to 1.03) and a significantly lower risk of MB (hazard ratio: 0.62; 95% confidence
interval: 0.54 to 0.70) versus warfarin. No significant interaction was observed between
treatment and obesity status (nonobese, obese/nonmorbid, obese/morbid) for stroke/SE
(interaction p = 0.602) or MB (interaction p = 0.385). In obese patients with NVAF,
apixaban was associated with a similar risk of stroke/SE and a significantly lower
risk of MB versus warfarin.
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References
Centers for Disease Control and Prevention. Heart disease: Atrial fibrillation. (Available at:) https://www.cdc.gov/heartdisease/atrial_fibrillation.htm. Date: September 8, 2020. Accessed January 8, 2021.
- Epidemiology of atrial fibrillation in the 21st century: novel methods and new insights.Circ Res. 2020; 127: 4-20
- Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population.Am J Cardiol. 2013; 112: 1142-1147
- Stroke Prevention in Patients with Atrial Fibrillation: A Systematic Review Update.Agency for Healthcare Research and Quality, Rockville2018: 609
- Incidence and prevalence of atrial fibrillation and associated mortality among Medicare beneficiaries: 1993–2007.Circ Cardiovasc Qual Outcomes. 2012; 5: 85-93
- Stroke prevention with oral anticoagulation in older people with atrial fibrillation - A pragmatic approach.Aging Dis. 2012; 3: 339-351
- Effectiveness and safety of oral anticoagulants among NVAF patients with obesity: insights from the Aristophanes study.J Clin Med. 2020; 9: 1633
Centers for Disease Control and Prevention. Overweight & Obesity: Adult Obesity Facts. Available at: https://www.cdc.gov/obesity/data/adult.html. Date: February 11, 2021. Accessed March 5, 2021.
- Projected U.S. state-level prevalence of adult obesity and severe obesity.N Engl J Med. 2019; 381: 2440-2450
- Apixaban versus warfarin in patients with atrial fibrillation.N Engl J Med. 2011; 365: 981-992
- RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation.N Engl J Med. 2009; 361: 1139-1151
- Rivaroxaban-once daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation: rationale and design of the ROCKET AF study.Am Heart J. 2010; 159 (e1): 340-347
- ENGAGE AF: effective anticoagulation with factor Xa in next generation treatment of atrial fibrillation.Glob Cardiol Sci Pract. 2013; 2013: 354-356
- 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2019; 74: 104-132
- Assessing bleeding risk in patients taking anticoagulants.J Thromb Thrombolysis. 2013; 35: 312-319
- Relation of risk of stroke in patients with atrial fibrillation to body mass index (from patients treated with Rivaroxaban and warfarin in the Rivaroxaban once daily oral direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation trial).Am J Cardiol. 2017; 119: 1989-1996
- The 'obesity paradox' in atrial fibrillation: observations from the Aristotle (apixaban for reduction in stroke and other thromboembolic events in atrial fibrillation) trial.Eur Heart J. 2016; 37: 2869-2878
- Direct oral anticoagulants in extremely obese patients: OK to use?.Res Pract Thromb Haemost. 2019; 3: 152-155
- Anticoagulation at the extremes of body weight: choices and dosing.Expert Rev Hematol. 2018; 11: 817-828
- Use of the direct oral anticoagulants in obese patients: guidance from the SSC of the ISTH.J Thromb Haemost. 2016; 14: 1308-1313
- Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies.Stat Med. 2015; 34: 3661-3679
- A primer on inverse probability of treatment weighting and marginal structural models.Emerg Adulthood. 2016; 4: 40-59
- Use of stabilized inverse propensity scores as weights to directly estimate relative risk and its confidence intervals.Value Health. 2010; 13: 273-277
- The use of propensity score methods with survival or time-to-event outcomes: reporting measures of effect similar to those used in randomized experiments.Stat Med. 2014; 33: 1242-1258
- Effectiveness and safety of apixaban versus warfarin in non-valvular atrial fibrillation patients in "real-world" clinical practice. A propensity-matched analysis of 76,940 patients.Thromb Haemost. 2017; 117: 1072-1082
- Comparative clinical outcomes between direct oral anticoagulants and warfarin among elderly patients with non-valvular atrial fibrillation in the CMS Medicare population.J Thromb Thrombolysis. 2019; 48: 240-249
- Effectiveness and safety of oral anticoagulants among nonvalvular atrial fibrillation patients.Stroke. 2018; 49: 2933-2944
- Exploring the obesity paradox in atrial fibrillation. AFBAR (Atrial Fibrillation Barbanza Area) registry results.J Atr Fibrillation. 2014; 6: 991
- Influence of obesity on outcomes in atrial fibrillation: yet another obesity paradox.Am J Med. 2010; 123: 646-651
- Obesity and outcomes among patients with established atrial fibrillation.Am J Cardiol. 2010; 106: 369-373
- Obesity paradox in patients with atrial fibrillation and heart failure.Int J Cardiol. 2014; 176: 1356-1358
- Atrial fibrillation in women: epidemiology, pathophysiology, presentation, and prognosis.Nat Rev Cardiol. 2016; 13: 321-332
Article info
Publication history
Received in revised form:
September 13,
2021
Received:
July 6,
2021
Identification
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