A case-control study on direct oral anticoagulants versus warfarin for acute pulmonary embolism in obese patients

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<b>Background:</b> Long-term outcome data on direct oral anticoagulants (DOACs) for treating acute pulmonary embolism (PE) in obesity is limited. <b>Aim:</b> We evaluated the efficacy and safety of DOACs compared to warfarin in obesity associated PE. <b>Methods:</b> A multisite propensity-scores matched case-control study was performed. Adults with a BMI &gt;30kg/m² with acute PE requiring hospital admission and initiated on anticoagulation were eligible, and matched 2:1 to DOAC and warfarin groups. Outcomes were compared at six-months. <b>Results:</b> Out of 1682 hospital presentations with acute PE during the study period, 271 patients (median age 59 years [IQR 41-78]) met inclusion criteria and underwent matching to DOACs (N=154) and warfarin (N=77) groups. Recurrent VTE rate within six-months was 5.8% (n=9) in DOAC group compared to 6.6% (n=5) in warfarin group (OR 0.89; 95%CI 0.3-2.8, p=0.85). Overall rate of bleeding complications was similar between DOACs and warfarin groups (14.3% vs 16.9% respectively, OR 0.82; 95%CI 0.4–1.7, p=0.60). Thirty-day mortality was 1.3% (n=2) in DOAC group and 3.9% (n=3) in warfarin group (OR 0.32; 95%CI 0.1-2.0, p=0.22). Morbidly obese (BMI &gt;40 kg/m² or weight &gt;120kg) patients had similar recurrent VTE rates (5.8% in the DOAC group vs 6.8% in the warfarin group (OR 0.89; 95% CI 0.2-3.6, p=0.82)) and bleeding complications. In patients with intermediate or high-risk PE, the rate of recurrent VTE was 4.3% (n=5) in DOAC group compared to 6.6% (n=4) in warfarin group (OR 0.65; 95%CI 0.2-2.5, p=0.52). <b>Conclusion:</b> Anticoagulation with DOACs appears to be effective and safe in obese patients with acute PE compared to warfarin, including in intermediate or high-risk PE.