Proietti Marco, Guiducci Elisa, Cheli Paola, Lip Gregory Y H
From the University of Birmingham Institute of Cardiovascular Sciences, Birmingham, United Kingdom (M.P., E.G., P.C., G.Y.H.L.); Department of Internal Medicine and Medical Specialties (M.P., E.G.) and Department of Life, Health and Environmental Sciences (P.C.), University of L'Aquila, Italy; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark (G.Y.H.L.).
Stroke. 2017 Apr;48(4):857-866. doi: 10.1161/STROKEAHA.116.015984. Epub 2017 Mar 6.
Obesity is a risk factor for all-cause and cardiovascular death but, despite this, an inverse relationship between overweight or obesity and a better cardiovascular prognosis in long-term follow-up studies has been observed; this phenomenon, described as obesity paradox, has also been found evident in atrial fibrillation cohorts.
We performed a systematic review on the relationship between body mass index and major adverse outcomes in atrial fibrillation patients. Moreover, we provided a meta-analysis of non-vitamin K antagonist oral anticoagulants (NOACs) trials.
An obesity paradox was found for cardiovascular death and all-cause death in the subgroup analyses of randomized trial cohorts; however, observational studies fail to show this relationship. From the meta-analysis of NOAC trials, a significant obesity paradox was found, with both overweight and obese patients reporting a lower risk for stroke/systemic embolic event (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.66-0.84 and OR, 0.62; 95% CI, 0.54-0.70, respectively). For major bleeding, only obese patients were at lower risk compared with normal weight patients (OR, 0.84; 95% CI, 0.72-0.98). A significant treatment effect of NOACs was found in normal weight patients, both for stroke/systemic embolic event (OR, 0.66; 95% CI, 0.56-0.78) and for major bleeding (OR, 0.72; 95% CI, 0.54-0.95). Major bleeding risk was lower in overweight patients treated with NOACs (OR, 0.84; 95% CI, 0.71-1.00).
There may be an obesity paradox in atrial fibrillation patients, particularly for all-cause and cardiovascular death outcomes. An obesity paradox was also evident for stroke/systemic embolic event outcome in NOAC trials, with a treatment effect favoring NOACs over warfarin for both efficacy and safety that was significant only for normal weight patients.
肥胖是全因死亡和心血管死亡的危险因素，但尽管如此，在长期随访研究中观察到超重或肥胖与较好的心血管预后之间存在负相关关系；这种现象被称为肥胖悖论，在房颤队列中也很明显。
我们对体重指数与房颤患者主要不良结局之间的关系进行了系统评价。此外，我们对非维生素K拮抗剂口服抗凝剂（NOACs）试验进行了荟萃分析。
在随机试验队列的亚组分析中发现了心血管死亡和全因死亡的肥胖悖论；然而，观察性研究未能显示这种关系。从NOAC试验的荟萃分析中，发现了显著的肥胖悖论，超重和肥胖患者发生卒中/全身性栓塞事件的风险均较低（优势比[OR]分别为0.75；95%置信区间[CI]为0.66 - 0.84和OR为0.62；95%CI为0.54 - 0.70）。对于大出血，只有肥胖患者与正常体重患者相比风险较低（OR为0.84；95%CI为0.72 - 0.98）。在正常体重患者中发现NOACs对卒中/全身性栓塞事件（OR为0.66；95%CI为0.56 - 0.78）和大出血（OR为0.72；95%CI为0.54 - 0.95）均有显著治疗效果。接受NOACs治疗的超重患者大出血风险较低（OR为0.84；95%CI为0.71 - 1.00）。
房颤患者中可能存在肥胖悖论，特别是在全因和心血管死亡结局方面。在NOAC试验中，卒中/全身性栓塞事件结局的肥胖悖论也很明显，在疗效和安全性方面，NOACs相对于华法林的治疗效果仅在正常体重患者中显著。
