Brar Tanveer, Chua Doson
Pharmacy Department, St Paul's Hospital, Vancouver, British Columbia, Canada.
Pharmacy Department, St Paul's Hospital, Vancouver, British Columbia, Canada.
Can J Cardiol. 2021 Sep;37(9):1489-1492. doi: 10.1016/j.cjca.2021.04.004. Epub 2021 Apr 15.
Anticoagulation with direct-acting oral anticoagulants (DOACs) is recommended over warfarin for stroke prevention in patients with atrial fibrillation (AF). The efficacy of DOACs over warfarin in obese patients with AF is less defined and may carry the potential for subtherapeutic anticoagulation and reduced efficacy. The best available evidence to guide DOAC use in obese patients with AF is from analysis of obese subgroups of all the major landmark DOAC trials. From these subgroup analyses of the RE-LY, ARISTOTLE, ENGAGE-AF TIMI 48, and ROCKET-AF trials, DOAC use in obese patients demonstrated efficacy similar or superior to warfarin for stroke reduction. Major bleeding rates were similar or higher with DOACs compared with warfarin in these obese subgroup analyses. Meta-analysis of the above major clinical trials concluded that DOACs were more effective compared with warfarin for stroke prevention in obese patients (up to a body mass index [BMI] of 50 kg/m) and had lower incidence of major bleeding. The totality of evidence supports that DOACs are as effective, if not superior, to warfarin in obese patients with AF. We propose an algorithm, based on the available evidence and current guidelines, to guide the use of DOACs based on severity of obesity. Any DOAC can be used in obese patients with BMI < 40 kg/m. In patients with a BMI of 40-50 kg/m, warfarin should be used, but apixaban or edoxaban can be considered. In obese patients with a BMI > 50 kg/m, warfarin should be used.
对于心房颤动（AF）患者的卒中预防，推荐使用直接作用口服抗凝剂（DOACs）进行抗凝治疗，而非华法林。DOACs对比华法林在肥胖AF患者中的疗效尚不明确，可能存在抗凝不足及疗效降低的风险。指导肥胖AF患者使用DOACs的最佳现有证据来自对所有主要标志性DOAC试验中肥胖亚组的分析。从RE-LY、ARISTOTLE、ENGAGE-AF TIMI 48和ROCKET-AF试验的这些亚组分析来看，肥胖患者使用DOACs在降低卒中方面显示出与华法林相似或更优的疗效。在这些肥胖亚组分析中，DOACs的主要出血率与华法林相似或更高。对上述主要临床试验的荟萃分析得出结论，在肥胖患者（体重指数[BMI]高达50 kg/m²）中，DOACs在预防卒中方面比华法林更有效，且主要出血发生率更低。总体证据支持，在肥胖AF患者中，DOACs即使不比华法林更优，至少与华法林一样有效。我们基于现有证据和当前指南提出一种算法，以根据肥胖严重程度指导DOACs的使用。BMI < 40 kg/m²的肥胖患者可使用任何DOACs。BMI为40 - 50 kg/m²的患者应使用华法林，但也可考虑使用阿哌沙班或依度沙班。BMI > 50 kg/m²的肥胖患者应使用华法林。
