Risks and benefits of oral anticoagulants for stroke prophylaxis in atrial fibrillation according to body mass index: Nationwide cohort study of primary care records in England

Nakao, Yoko M.; Nakao, Kazuhiro; Wu, Jianhua; Nadarajah, Ramesh; Gale, Chris P

doi:10.1016/j.eclinm.2022.101709

Cited by 9 publications

(6 citation statements)

References 24 publications

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“…Residents classified as underweight had a higher prevalence of OAC discontinuation before hospice enrollment. This finding is consistent with previous research indicating that an increased risk of bleeding would outweigh the benefits of reducing stroke risk among underweight patients with atrial fibrillation 34 . In our study, residents with one or more hospital admissions during the year prior to hospice enrollment had a higher prevalence of OAC discontinuation before hospice enrollment.…”

Section: Discussionsupporting

confidence: 92%

“…This finding is consistent with previous research indicating that an increased risk of bleeding would outweigh the benefits of reducing stroke risk among underweight patients with atrial fibrillation. 34 In our study, residents with one or more hospital admissions during the year prior to hospice enrollment had a higher prevalence of OAC discontinuation before hospice enrollment. This may reflect an earlier emphasis on symptom management and palliative care for residents with acute clinical deterioration and engagement with a broader care team in the inpatient setting compared with residents who did not experience such transitions of care.…”

Section: Factors Associated With Discontinuation Of Oac Usementioning

confidence: 50%

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Discontinuation of oral anticoagulant use among nursing home residents with atrial fibrillation before hospice enrollment

Chen

Baek

Goldberg

et al. 2023

J American Geriatrics Society

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BackgroundOral anticoagulants (OACs) are effective in reducing the risk of cardioembolic stroke due to atrial fibrillation. While most nursing home residents with atrial fibrillation qualify for anticoagulation based on clinical guidelines, the net clinical benefits of OACs may diminish as residents approach the end of life.MethodsWe conducted a cross‐sectional study of 30,503 US nursing home residents with atrial fibrillation (based on Minimum Data Set 3.0 and Medicare Part A records) who used OACs in the year before enrolling in hospice care during 2012–2016. Whether residents discontinued OACs before hospice enrollment was determined using Part D claims and date of hospice enrollment. Modified Poisson models estimated adjusted prevalence ratios (aPR).ResultsAlmost half (45.7%) of residents who had recent OAC use discontinued prior to hospice enrollment. Residents who were underweight (aPR: 1.02; 95% confidence interval [CI]: 1.01–1.03), those with high bleeding risk (aPR: 1.04, 95% CI: 1.03–1.05), and those with moderate or severe cognitive impairment (aPR: 1.02, 95% CI: 1.02–1.03) had a higher prevalence of OAC discontinuation before entering hospice. Residents with venous thromboembolism (aPR: 0.94, 95% CI: 0.93–0.96), statin users (aPR: 0.88, 95% CI: 0.87–0.89), and those on polypharmacy (≥10 medications, aPR: 0.72; 95% CI: 0.71–0.73) were less likely to discontinue OACs before enrollment in hospice.ConclusionAnticoagulants are often discontinued among older nursing home residents with atrial fibrillation before hospice enrollment; it is not clear that these decisions are driven solely by net clinical benefit considerations. Further research is needed on comparative outcomes to inform resident‐centered decisions regarding OAC use in older adults entering hospice.

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Section: Discussionsupporting

confidence: 92%

Section: Factors Associated With Discontinuation Of Oac Usementioning

confidence: 50%

Discontinuation of oral anticoagulant use among nursing home residents with atrial fibrillation before hospice enrollment

Chen

Baek

Goldberg

et al. 2023

J American Geriatrics Society

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“…Six studies reported composite outcomes in patients with LBW [ 28 – 31 , 33 , 36 ]. Prescribing DOACs in patients with LBW with atrial fibrillation had a consistent non-significant trend toward an overall reduced composite outcome by 19% (OR 0.81, 95% CI 0.59–1.09, Q = 7.67, I 2 = 42.24%; Fig 2 ).…”

Section: Resultsmentioning

confidence: 99%

“…Six studies evaluated mortality outcomes in patients with LBW [ 31 – 36 ]. These studies showed no significant difference in mortality associated with DOACs compared with warfarin.…”

Section: Resultsmentioning

confidence: 99%

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Comparative Effectiveness and Safety of Direct Oral Anticoagulants Compared with Warfarin in Patients with Low Bodyweight who have Atrial Fibrillation: A Systematic Review and Meta-analysis

Elshafei,

El-Bardissy,

Salem

et al. 2024

Am J Cardiovasc Drugs

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Introduction oral anticoagulant (DOAC) agents are becoming the anticoagulation strategy of choice for most clinical risks for which they are indicated. However, residual uncertainty remains regarding their use in preventing stroke in patients with low bodyweight [< 60 kg or body mass index (BMI) < 18 kg/m 2 ]. We have carried out pooled systematic analyses of published studies to determine the efficacy and safety of these agents compared with warfarin in stroke prevention in patients with low bodyweight. Methods We carried out a comprehensive search of electronic databases from inception to June 2023 for eligible studies reporting on the efficacy and safety of direct oral anticoagulants versus warfarin in patients with atrial fibrillation who had low bodyweight. These include PubMed, EMBASE, the Cochrane Database of Systematic Reviews, the Science Citation Index, and the Database of Abstracts of Reviews of Effectiveness. Using the random effects model, derived pooled odd ratios (with their corresponding confidence intervals) of mortality outcomes in patient cohorts exposed to direct oral anticoagulants versus warfarin in patients with atrial fibrillation who had low bodyweight. Results Nine studies ( n = 159,514 patients) were included in our meta-analysis. DOAC analogs were associated with lower stroke recurrence compared with warfarin [odds ratio (OR) 0.66, 95% confidence interval (CI) 0.49–0.9]; however, there was no significant difference in the composite outcome (OR 0.81, 95% CI 0.59–1.09) and mortality (OR 0.82, 95% CI 0.48–1.41). Additionally, DOAC analogs showed a significant reduction in major bleeding events by 30% compared with warfarin (OR 0.70, 95% CI 0.62–0.80). Conclusion In this pooled meta-analytical synthesis of studies comprising both real-world and randomized controlled data, the use of DOAC analogs in patients with atrial fibrillation and low bodyweight (< 60 kg or BMI < 18 kg/m 2 ) was associated with a significant reduction in risks of stroke and major bleeding compared with patient cohorts stabilized on warfarin-based therapy. There was uncertainty regarding the composite outcome and mortality point estimate between these two anticoagulation strategies. This finding helps to resolve the uncertainty associated with the use of DOACs in this cohort. Additionally, it suggests the need for confirmatory non-inferiority randomized controlled trials evaluating DOACs versus warfarin in this cohort of patients.

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Safety and efficacy of direct oral anticoagulants in comparison to warfarin in obese patients with atrial fibrillation: A systematic review and meta‐analysis

Adelkhanova,

Oli,

Shrestha

et al. 2024

Health Science Reports

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Background and AimObesity affects nearly 650 million adults worldwide, and the prevalence is steadily rising. This condition has significant adverse effects on cardiovascular health, increasing the risk of hypertension, coronary artery disease, heart failure, and atrial fibrillation (AF). While anticoagulation for obese patients with AF is a well‐established therapy for the prevention of thromboembolism, the safety and efficacy of different anticoagulants in this specific population are not well explored. This meta‐analysis aimed to compare direct oral anticoagulants (DOAC) to vitamin K antagonists in obese populations with AF.MethodsThe PRISMA guidelines were followed for this meta‐analysis, registered in PROSPERO (CRD42023392711). PubMed, PubMed Central, Embase, Cochrane Library, and Scopus databases were searched for relevant articles from inception through January 2023. Two independent authors screened titles and abstracts, followed by a full‐text review in Covidence. Data were extracted in Microsoft Excel and analyzed using RevMan v5.4 using odds ratio as an effect measure.ResultsTwo thousand two hundred fifty‐nine studies were identified from the database search, and 18 were included in the analysis. There were statistically significant reductions in the odds of ischemic and hemorrhagic stroke in the DOAC group compared with the VKA group (OR 0.70, CI 0.66–0.75) and (OR 0.47, CI 0.35–0.62), respectively. In addition, the DOAC group exhibited lower odds of systemic embolism (OR 0.67, CI 0.54–0.83), major bleeding (OR 0.62, CI 0.54–0.72), and composite outcome (OR 0.72, CI 0.63–0.81).ConclusionBased on the findings from this meta‐analysis, DOACs demonstrate superior safety and efficacy in obese patients with AF compared with VKAs. These results may have significant implications for guiding anticoagulation strategies in this patient population.

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Risks and benefits of oral anticoagulants for stroke prophylaxis in atrial fibrillation according to body mass index: Nationwide cohort study of primary care records in England

Cited by 9 publications

References 24 publications

Discontinuation of oral anticoagulant use among nursing home residents with atrial fibrillation before hospice enrollment

Discontinuation of oral anticoagulant use among nursing home residents with atrial fibrillation before hospice enrollment

Comparative Effectiveness and Safety of Direct Oral Anticoagulants Compared with Warfarin in Patients with Low Bodyweight who have Atrial Fibrillation: A Systematic Review and Meta-analysis

Safety and efficacy of direct oral anticoagulants in comparison to warfarin in obese patients with atrial fibrillation: A systematic review and meta‐analysis

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