ORIGINAL PAPER
Body mass index and adverse cardiovascular events in individuals with atrial fibrillation taking oral anticoagulants: a prospective, observational, long-term follow-up cohort study
1
Faculty of Medicine, Jan Kochanowski University, Kielce, Poland
Submission date: 2025-05-04
Acceptance date: 2025-06-14
Publication date: 2026-06-29
Medical Studies 2026;42(2):214-223
KEYWORDS
anticoagulationatrial fibrillationbody mass indexcardiovascular outcomesleft atrial appendage thrombus
TOPICS
ABSTRACT
Introduction:
Obesity is a known variable associated with increased risk of atrial fibrillation (AF); however, the impact of body mass index (BMI) on adverse cardiovascular outcomes in individuals with AF taking anticoagulants is not well established.
Aim:
This study aimed to evaluate the association between BMI categories (normal weight, overweight, and obese) and adverse cardiovascular outcomes in individuals with AF taking anticoagulants.
Material and methods:
This prospective, observational, long-term follow-up cohort study included 500 individuals with AF who underwent transoesophageal echocardiography before electrical cardioversion. Individuals were stratified by BMI and followed up for a median of 1927.5 days. Endpoints included major cardiovascular events (stroke, myocardial infarction, transient ischaemic attack, systemic thromboembolism, hospitalisation for heart failure, and cardiovascular death) and left atrial appendage thrombus (LAAT).
Results:
Adverse cardiovascular event rates were similar across BMI categories. Individuals with normal weight presented with fewer comorbidities, such as diabetes mellitus and arterial hypertension, and demonstrated more favourable echocardiographic measurements, including smaller left atrial diameters. Despite these differences, no significant variations in LAAT prevalence or other adverse cardiovascular outcomes were observed between the BMI groups. BMI did not significantly influence long-term adverse cardiovascular outcomes or LAAT in individuals with AF taking anticoagulants. The low proportion of normal-weight individuals in the cohort suggests a potential protective role of normal weight against AF.
Conclusions:
Further research is required to understand the complex interplay among BMI, comorbidities, and cardiovascular risk. These findings question the utility of BMI as a standalone risk predictor in this population.
Obesity is a known variable associated with increased risk of atrial fibrillation (AF); however, the impact of body mass index (BMI) on adverse cardiovascular outcomes in individuals with AF taking anticoagulants is not well established.
Aim:
This study aimed to evaluate the association between BMI categories (normal weight, overweight, and obese) and adverse cardiovascular outcomes in individuals with AF taking anticoagulants.
Material and methods:
This prospective, observational, long-term follow-up cohort study included 500 individuals with AF who underwent transoesophageal echocardiography before electrical cardioversion. Individuals were stratified by BMI and followed up for a median of 1927.5 days. Endpoints included major cardiovascular events (stroke, myocardial infarction, transient ischaemic attack, systemic thromboembolism, hospitalisation for heart failure, and cardiovascular death) and left atrial appendage thrombus (LAAT).
Results:
Adverse cardiovascular event rates were similar across BMI categories. Individuals with normal weight presented with fewer comorbidities, such as diabetes mellitus and arterial hypertension, and demonstrated more favourable echocardiographic measurements, including smaller left atrial diameters. Despite these differences, no significant variations in LAAT prevalence or other adverse cardiovascular outcomes were observed between the BMI groups. BMI did not significantly influence long-term adverse cardiovascular outcomes or LAAT in individuals with AF taking anticoagulants. The low proportion of normal-weight individuals in the cohort suggests a potential protective role of normal weight against AF.
Conclusions:
Further research is required to understand the complex interplay among BMI, comorbidities, and cardiovascular risk. These findings question the utility of BMI as a standalone risk predictor in this population.
REFERENCES (39)
1.
Yang X, Geng T, Peng Y, Cui L, Chen S, Wang G Gao X, Wu S. Associations between cardiac arrhythmias and cardiovascular disease incidence and all-cause mortality: the Kailuan study. BMC Public Health. 2024; 24: 3266.
2.
Turek Ł, Sadowski M, Janion-Sadowska A, Kurzawski J, Jaroszyński A. Left atrial appendage thrombus in patients referred for electrical cardioversion for atrial fibrillation: a prospective single center study. Pol Arch Intern Med. 2022; 132: 16214.
3.
Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJ, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D; ESC Scientific Document Group. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024; 45: 3314-414.
4.
Turek Ł, Sadowski M, Kurzawski J, Janion M. Left atrial appendage thrombus as a marker of disease severity in 500 patients with atrial fibrillation on oral anticoagulation: a 13-year follow-up study. J Clin Med. 2024; 13: 5258.
5.
Staerk L, Sherer JA, Ko D, Benjamin EJ, Helm RH. Atrial fibrillation: epidemiology, pathophysiology, and clinical outcomes. Circ Res. 2017; 120: 1501-1517.
6.
Visseren FL, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B; ESC National Cardiac Societies; ESC Scientific Document Group. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021; 42: 3227-3337.
7.
Sha R, Baines O, Hayes A, Tompkins K, Kalla M, Holmes AP, O’Shea C, Pavlovic D. Impact of obesity on atrial fibrillation pathogenesis and treatment options. J Am Heart Assoc. 2024; 13: e032277.
8.
Nteli M, Nteli D, Moysidis DV, Foka A, Zymaris P, Grantza T, Kazarli O, Vagianos A, Papazoglou AS, Kartas A, Samaras A, Bekiaridou A, Spyridonidis E, Ziakas A, Tzi- kas A, Giannakoulas G. Prognostic impact of body mass index in atrial fibrillation. J Clin Med. 2024; 13: 3294.
9.
Badheka AO, Rathod A, Kizilbash MA, Garg N, Mohamad T, Afonso L, Jacob S. Influence of obesity on outcomes in atrial fibrillation: yet another obesity paradox. Am J Med. 2010; 123: 646-651.
10.
Wang J, Yang YM, Zhu J, Zhang H, Shao XH, Tian L, Huang B, Yu LT, Gao X, Wang M. Overweight is associated with improved survival and outcomes in patients with atrial fibrillation. Clin Res Cardiol. 2014; 103: 533-542.
11.
Sandhu RK, Ezekowitz J, Andersson U, Alexander JH, Granger CB, Halvorsen S, Hanna M, Hijazi Z, Jansky P, Lopes RD, Wallentin L. The ‘obesity paradox’ in atrial fibrillation: observations from the Aristotle (Apixaban for Reduction in Stroke and Other thromboembolic Events in atrial fibrillation) trial. Eur Heart J. 2016; 37: 2869-2878.
12.
Ardestani A, Hoffman HJ, Cooper HA. Obesity and outcomes among patients with established atrial fibrillation. Am J Cardiol. 2010; 106: 369-373.
13.
Pandey A, Gersh BJ, McGuire DK, Shrader P, Thomas L, Kowey PR, Mahaffey KW, Hylek E, Sun S, Burton P, Piccini J, Peterson E, Fonarow GC. Association of body mass index with care and outcomes in patients with atrial fibrillation: results from the ORBIT-AF registry. JACC Clin Electrophysiol. 2016; 2: 355-363.
14.
Overvad TF, Rasmussen LH, Skjøth F, Overvad K, Lip GY, Larsen TB. Body mass index and adverse events in patients with incident atrial fibrillation. Am J Med. 2013; 126: 640.e9-17:e649-617.
15.
Wang HJ, Si QJ, Shan ZL, Guo YT, Lin K, Zhao XN, Wang YT. Effects of body mass index on risks for ischemic stroke, thromboembolism, and mortality in Chinese atrial fibrillation patients: a single-center experience. PLoS One. 2015; 10: e0123516.
16.
Patti G, Pecen L, Manu MC, Huber K, Rohla M, Renda G, Siller-Matula J, Ricci F, Kirchhof P, De Caterina R. Thromboembolic and bleeding risk in obese patients with atrial fibrillation according to different anticoagulation strategies. Int J Cardiol. 2020; 318: 67-73.
17.
Uziębło-Życzkowska B, Kapłon-Cieślicka A, Kiliszek M, Gawałko M, Budnik M, Starzyk K, Wożakowska-Kapłon B, Daniłowicz-Szymanowicz L, Kaufmann D, Wójcik M, Błaszczyk R, Hiczkiewicz J, Łojewska K, Mizia-Stec K, Wybraniec MT, Kosmalska K, Fijałkowski M, Szymańska A, Gos A, Haberka M, Kucio M, Michalski B, Kupczyńska K, Tomaszuk-Kazberuk A, Wilk-Śledziewska K, Wachnicka-Truty R, Koziński M, Burchardt P, Krzesiński P. Increased body mass index and risk of left atrial thrombus in nonvalvular atrial fibrillation patients-data from the left atrial thrombus on transesophageal echocardiography (LATTEE) registry. Nutrients. 2022; 14: 3652.
18.
Tang RB, Liu XH, Kalifa J, Li ZA, Dong JZ, Yang Y, Liu XP, Long DY, Yu RH, Ma CS. Body mass index and risk of left atrial thrombus in patients with atrial fibrillation. Am J Cardiol. 2009; 104: 1699-1703.
19.
European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De Caterina R, De Sutter J, Goette A, Gorenek B, Heldal M, Hohloser SH, Kolh P, Le Heuzey JY, Ponikowski P, Rutten FH. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010; 31: 2369-2429.
20.
Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P; ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012; 33: 2719-2747.
21.
Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P; European Heart Rhythm Association. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2013; 15: 625-651.
22.
Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2015; 17: 1467-1507.
23.
Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, Kusek JW, Van Lente F; Chronic Kidney Disease Epidemiology Collaboration. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med. 2006; 145: 247-254.
24.
Kasprzak JD, Hoffman P, Płońska E, Szyszka A, Braksator W, Gackowski A, Plewka M, Drożdż J, Gąsior Z, Prusz- czyk P, Klisiewicz A, Kowalski M, Podolec P. Echokardiografia w praktyce klinicznej. Standardy Sekcji Echokardiografii Polskiego Towarzystwa Kardiologicznego 2007. Kardiol Pol. 2007; 65: 1142-1162.
25.
Lang RM, Bierig M, Devereux RB, Flachskampf FA, Fo- ster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise J, Solomon S, Spencer KT, St John Sutton M, Stewart W; American Society of Echocardiography’s Nomenclature and Standards Committee; Task Force on Chamber Quantification; American College of Cardiology Echocardiography Committee; American Heart Association; European Association of Echocardiography, European Society of Cardiology. Recommendations for chamber quantification. Eur J Echocardiogr. 2006; 7: 79-108.
26.
Seidl K, Rameken M, Drögemüller A, Vater M, Brandt A, Schwacke H, Bergmeier C, Zahn R, Senges J. Embolic events in patients with atrial fibrillation and effective anticoagulation: value of transesophageal echocardiography to guide direct-current cardioversion. Final results of the Ludwigshafen Observational cardioversion Study. J Am Coll Cardiol. 2002; 39: 1436-1442.
27.
Writing Group Members, Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER 3rd, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB; American Heart Association Statistics Committee; Stroke Statistics Subcommittee. Heart disease and stroke Statistics-2016 update: A report from the American Heart Association. Circulation. 2016; 133: e38-e360.
28.
Powell-Wiley TM, Poirier P, Burke LE, Després JP, Gordon-Larsen P, Lavie CJ, Lear SA, Ndumele CE, Neeland IJ, Sanders P, St-Onge MP; American Heart Association Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Epidemiology and Prevention; and Stroke Council. Obesity and cardiovascular disease: A scientific statement from the American Heart Association. Circulation. 2021; 143: e984-e1010.
29.
January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW; ACC/AHA Task Force Members et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014; 130: e199-e267.
30.
Wanahita N, Messerli FH, Bangalore S, Gami AS, Somers VK, Steinberg JS. Atrial fibrillation and obesity – results of a meta-analysis. Am Heart J. 2008; 155: 310-315.
31.
Asad Z, Abbas M, Javed I, Korantzopoulos P, Stavrakis S. Obesity is associated with incident atrial fibrillation independent of gender: a meta-analysis. J Cardiovasc Electrophysiol. 2018; 29: 725-732.
32.
Grymonprez M, Capiau A, De Backer TL, Steurbaut S, Boussery K, Lahousse L. The impact of underweight and obesity on outcomes in anticoagulated patients with atrial fibrillation: a systematic review and meta-analysis on the obesity paradox. Clin Cardiol. 2021; 44: 599-608.
33.
Zhou Y, Ma J, Zhu W. Efficacy and safety of direct oral anticoagulants versus warfarin in patients with atrial fibrillation across BMI categories: a systematic review and meta-analysis. Am J Cardiovasc Drugs. 2020; 20: 51-60.
34.
Proietti M, Guiducci E, Cheli P, Lip GY. Is there an obesity paradox for outcomes in atrial fibrillation? A systematic review and meta-analysis of non-vitamin K antagonist oral anticoagulant trials. Stroke. 2017; 48: 857-866.
35.
Agarwal MA, Garg L, Shah M, Patel B, Jain N, Jain S, Kabra R, Kovesdy C, Reed GL, Lavie CJ. Relation of obesity to outcomes of hospitalizations for atrial fibrillation. Am J Cardiol. 2019; 123: 1448-1452.
36.
Zhu W, Wan R, Liu F, Hu J, Huang L, Li J, Hong K. Relation of body mass index with adverse outcomes among patients with atrial fibrillation: a meta-analysis and systematic review. J Am Heart Assoc. 2016; 5: e004006.
37.
Caleyachetty R, Thomas GN, Toulis KA, Mohammed N, Gokhale KM, Balachandran K, Nirantharakumar K. Metabolically healthy obese and incident cardiovascular disease events among 3.5 million men and women. J Am Coll Cardiol. 2017; 70: 1429-1437.
38.
Fauchier G, Bisson A, Bodin A, Herbert J, Semaan C, Angoulvant D, Ducluzeau PH, Lip GYH, Fauchier L. Metabolically healthy obesity and cardiovascular events: a nationwide cohort study. Diabetes Obes Metab. 2021; 23: 2492-2501.
39.
Corica B, Romiti GF, Proietti M, Mei DA, Boriani G, Chao TF, Olshansky B, Huisman MV, Lip GYH; GLORIA-AF Investigators. Clinical outcomes in metabolically healthy and unhealthy obese and overweight patients with atrial fibrillation: findings from the Gloria-AF registry. Mayo Clin Proc. 2024; 99: 927-939.
Share
RELATED ARTICLE
| eISSN: | 2300-6722 |
| ISSN: | 1899-1874 |
We process personal data collected when visiting the website. The function of obtaining information about users and their behavior is carried out by voluntarily entered information in forms and saving cookies in end devices. Data, including cookies, are used to provide services, improve the user experience and to analyze the traffic in accordance with the Privacy policy. Data are also collected and processed by Google Analytics tool (more).
You can change cookies settings in your browser. Restricted use of cookies in the browser configuration may affect some functionalities of the website.
You can change cookies settings in your browser. Restricted use of cookies in the browser configuration may affect some functionalities of the website.
