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

Background Direct oral anticoagulants (DOACs) are effective and safe alternatives to warfarin for stroke prophylaxis for atrial fibrillation (AF). Whether this extends to patients at the extremes of body mass index (BMI) is unclear. Methods Using linked primary and secondary data, Jan 1, 2010 to Nov 30, 2018, we included CHA(2)DS(2)-VAS(C) score >= 3 in women and >= 2 in men with AF treated with oral anticoagulants (OACs). Outcomes were ischaemic stroke, major bleeding and all-cause mortality by World Health Organisation BMI classification. Patients who received warfarin were propensity score matched (1:1 ratio) with those who received DOACs and the association of time-varying OAC exposure on outcomes quantified using Cox proportional hazards models. Findings We included 29,135 (22,818 warfarin, 6317 DOAC); 585 (2.0%) underweight, 8427 (28.9%) normal weight, 10,705 (36.7%) overweight, 5910 (20.3%) class I obesity and 3508 (12.0%) class II/III obesity. Patients treated with DOACs were older and more comorbid. After 3.7 (SD 2.5) years follow up, there was no difference in risk of ischaemic stroke and major bleeding by BMI category between DOACs and warfarin. Normal weight, overweight and obese class I patients had higher risk of all-cause mortality when treated with DOACs compared with warfarin (HR: 1.45 [95% CI 1.24-1.69], p < 0.001; 1.41 [95% CI 1.19-1.66], p < 0.001; and 1.90 [95% CI 1.50-2.39], p < 0.001), an effect not observed after DOACs became the most common OAC prescription. Amongst underweight patients OAC exposure was associated with greater harm from bleeding than benefit from stroke prevention (benefit to harm ratio, 0.35 [95% CI 0.26-0.44]). Interpretation In patients with AF in each BMI classification we found no difference in ischaemic stroke and bleeding risk for DOACs compared with warfarin. Underweight patients experienced divergent risk-benefit patterns from oral anticoagulation compared with other BMI categories. Copyright (c) 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Automated summary

DOACs and warfarin showed no difference in the risk of ischemic stroke and bleeding for patients with atrial fibrillation (AF) in different BMI categories. However, normal weight, overweight, and obese class I patients had a higher risk of all-cause mortality when treated with DOACs compared to warfarin, an effect that disappeared after DOACs became the most commonly prescribed oral anticoagulants. Among underweight patients, the use of oral anticoagulation was associated with greater harm from bleeding than benefit from stroke prevention.