Antithrombotic therapy and body mass: an expert position paper of the ESC Working Group on Thrombosis

Abstract

Increasing prevalence of cardiovascular disease and new evidence on the effects of antithrombotic therapies have expanded the use of antiplatelet and anticoagulant drugs. In addition, extremely low and high body weights have become more common due to frailty associated with ageing and to the global epidemic of obesity, 'globesity', respectively. These extreme body weights affect cardiovascular risk, including mortality, as well as the pharmacokinetics and safety profiles of antithrombotic drugs, some of which have a relatively narrow therapeutic window.The ESC Working Group on Thrombosis therefore assembled a task group to examine the key issues related to this topic and to address the question of whether modified antithrombotic management strategies are required for patients at the extremes of body weight. Greater focus is directed toward to obesity, given its higher prevalence among patients with cardiovascular disease and its associated complexities in terms of pharmacology and pathophysiology.Further research is warranted to optimize antithrombotic therapy in underweight as well as in different classes of obese patients, to guide dosing, dose-adjustment and/or reference intervals, and to establish whether the balance of benefits and risks of antithrombotic drugs can be improved.

Prognostic characteristics and body mass index in patients with pulmonary embolism: does size matter?

“…Our findings of a trend towards worse prognostics in patients who are obese underlines the importance of more patient-centred care [38], in particular with respect to choosing the appropriate anticoagulant therapy for each individual patient. In this way, we can confirm the call for increased awareness on dedicated prophylactic and therapeutic anticoagulant regimens in obesity [7]. Reassuringly, a recent well-sized cohort study suggested similar efficacy and safety between direct oral anti-Xa inhibitors and warfarin in patients who are morbidly obese, although these retrospective findings warrant confirmation in prospective studies [39].…”

“…Regarding treatment, it is debated whether the patients at extremes in body weight should receive modified treatment regimens [7]. Because of limited clinical data available for patients who are obese, the International Society on Thrombosis and Haemostasis (ISTH) guidance document advises against the use of direct oral anticoagulants in patients with a body weight higher than 120 kg or a BMI higher than 40 [8].…”

“…Because of limited clinical data available for patients who are obese, the International Society on Thrombosis and Haemostasis (ISTH) guidance document advises against the use of direct oral anticoagulants in patients with a body weight higher than 120 kg or a BMI higher than 40 [8]. Although currently unfractioned heparin with activated partial thromboplastin time monitoring for patients with severe obesity is recommended [9], an expert panel recently expressed the urgent need for data on heparin regimens in all patients who are obese [7]. This becomes even more prominent with the alarming increase in people who are overweight worldwide [10].…”

Platelet-Derived Thrombogenicity Measured by Total Thrombus-Formation Analysis System in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

“…Obese adipose tissue amplifies the secretion of proinflammatory cytokines and chemokines, leading to platelet activation. 39 Intensive antithrombotic therapy may be effective for young patients with greater body weight; however, adjustment of drug doses based on body weight remains controversial with regard to bleeding risk due to overdose. 39 Further detailed analysis is necessary to assess the factors affecting PL18-AUC10 during PPCI.…”

Update and Unmet Needs on the Use of Nonvitamin K Oral Anticoagulants for Stroke Prevention in Patients With Atrial Fibrillation

“…A similar indication comes from the 2018 position paper of ESC Working group, that suggests a full standard dose of NOACs in patients with normal/grade I obesity (BMI <35 kg/m 2 ), with no/insufficient data for apixaban, edoxaban and dabigatran for obesity class II-III; conversely Rivaroxaban full dose can be administered with caution in patients with class II obesity (BMI 35-39.9 kg/m 2 ) 30 .…”