DOAC Use for Stroke Prevention in Patients with Atrial Fibrillation and Elevated Body Mass Index
Background: The incidence of comorbid obesity and atrial fibrillation (AF) has been increasing. Direct Oral Anticoagulants (DOACs) have become the first-line agents for cerebrovascular accident (CVA) prophylaxis in patients with AF due to their superior efficacy and lower bleeding risk when compared to coumadin. The incidence of acute ischemic CVA while on a DOAC in the non-obese population is 1.2%. Evidence on the efficacy of DOACs in preventing AF related CVAs in the obese population is limited.
Methods: Electronic medical records from 8 hospitals within the same health system were queried. Patients age > 18 years with a BMI > 40 kg/mm2 and AF on a DOAC (Rivaroxaban, Apixaban, or Dabigatran) were included in our study. Individual charts from 2010 to 2020 were reviewed for neuroimaging (computed tomography and MRI) following the start date of a DOAC confirming the presence or absence of an acute hemorrhagic or ischemic CVA.
Results: We included 1935 patients in the study. Acute ischemic CVA was noted in 17 patients (0.9%) by head CT (11/17 confirmed by MRI). Hemorrhagic CVA was noted in one patient (0.1%) by head CT. 155 (8%) had a head CT without evidence of CVA, of which, 5 (3.2 %) had evidence of an acute ischemic CVA by MRI. Therefore, 22 patients (1.1%) had evidence of acute ischemic CVA on neuroimaging. The remainder of patients (N = 1762, 91.1%) did not have indications for neuroimaging and were considered to have successful CVA prophylaxis. In total, 1912 (98.8%) of patients with a BMI > 40 treated with a DOAC for AF did not demonstrate neuroimaging evidence of CVA.
Conclusions: Although we expected to find higher CVA rates due to ineffective anticoagulation in the obese population, DOACs appear to be an effective therapy for CVA prophylaxis in obese patients with AF. The incidence of acute ischemic CVA in the obese population while on a DOAC is comparable to the non-obese population. Further prospective studies are needed to confirm the findings of this analysis.
Foglesong A, Armstrong J, Mando R, Halalau A. DOAC use for stroke prevention in patients with atrial fibrillation and elevated body mass index. Circulation. 2021 Nov 16;144(Suppl_1): A8899.