Temporal Trends in Direct-Acting Oral Anticoagulants Use Among Patients at Extremes of Body Weight: Insight From PINNACLE Registry

Objective To describe temporal changes in direct oral anticoagulant (DOAC) use across the range of body mass index (BMI) and understand factors associated with its use. Patients and Methods Outpatients with atrial fibrillation (AF) eligible for systemic anticoagulation in the PINNACLE Registry (January 1st, 2014-September 30th, 2021) were identified, and mixed-effects logistic regression was used to assess the association between DOAC use and BMI, after adjusting for patient characteristics, with an interaction between BMI and calendar year to describe temporal changes in practice. Results Of 950,644 patients with nonvalvular AF with a CHA₂DS₂-VASc score of ≥2 and no previous bleeding who were receiving oral anticoagulation, 66.4% were treated with DOAC, which markedly increased between 2014 and 2021 (40.2% and 84.4%, respectively). Although BMI was nonlinearly associated with DOAC use ( P _interaction=.0002), differences in DOAC use across BMI were small with rates of 63.2% in underweight patients, 64% in normal-weight patients, and 68.9% in those with class III obesity. Increases in DOAC use over time did not differ significantly across the BMI spectrum. Conclusion Despite limited safety and efficacy evidence for DOAC use in underweight and obese patients with nonvalvular AF, only modest differences exist in its use and growth over time. These data underscore the importance of future research in underweight and obese patients.