Comparing the Efficacy and Safety of Direct Oral Anticoagulants With Warfarin in the Morbidly Obese Population With Atrial Fibrillation

Background: The International Society of Thrombosis and Haemostasis recommends avoiding direct oral anticoagulants (DOACs) in morbidly obese patients with a body mass index (BMI) >40 kg/m 2 or weight >120 kg because of limited clinical data in this group of patients. Objectives: The objective of this study was to evaluate the efficacy and safety of DOACs in morbidly obese patients with atrial fibrillation or flutter. Methods: A retrospective, single-center cohort study was conducted of patients older than 18 years, with BMI >40 kg/m 2 or weight >120 kg, who were diagnosed as having atrial fibrillation or flutter and who received warfarin or DOACs (ie, dabigatran, rivaroxaban, or apixaban). The primary efficacy outcome was the incidence of ischemic stroke or transient ischemic attack (TIA), whereas the primary safety outcome was the incidence of major bleeding. Results: A total of 64 patients in each group were included in the study analysis. The incidence rate of ischemic stroke or TIA was 1.75%/year in the DOAC group compared with 2.07%/year in the warfarin group (rate ratio = 0.84; 95% CI = 0.23 to 3.14; P = 0.80). The incidence rate of major bleeding was 2.18%/year in the DOAC group, compared with 4.97%/year in the warfarin group (rate ratio = 0.44; 95% CI = 0.15 to 1.25; P = 0.11). Conclusion and Relevance: Apixaban and rivaroxaban may be considered as alternatives to warfarin for atrial fibrillation or flutter in morbidly obese patients. Dabigatran use in morbidly obese patients needs caution until further studies are conducted.