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There is little reported on the efficacy and safety of direct oral anticoagulants (DOACs) in morbid obesity after venous thromboembolism (VTE).  In this observational study, patients were followed up after intermediate- or high-risk pulmonary embolism (PE) at the University of Rochester Pulmonary Hypertension Clinic 2–4 months after the initial event. All patients had echocardiography and V/Q imaging regardless of symptoms. Outcomes of interest were the rates of recurrent VTE, thrombus resolution and development of chronic thromboembolic pulmonary hypertension (CTEPH) in patients with morbid obesity treated with a DOAC compared to treatment with vitamin K antagonists and to non-morbidly obese patients after PE. Using the electronic medical record, recurrent events were assessed up to 12 months after the event.  107 patients (body mass index (BMI)&gt;40 kg·m −2 , n=32; BMI 30–39.9 kg·m −2 , n=39; BMI 40 kg·m −2 , n=19; BMI 30–39.9 kg·m −2 , n=27; BMI&lt;30 kg·m −2 , n=24). There were no recurrent events within the first 12 months of initial diagnosis based on symptoms and imaging in any patient. There was no difference in rate of residual unmatched perfusion defect with DOACs or conventional anticoagulation (49%  versus  49%). This finding remained in the subset of morbidly obese patients (47%  versus  50%). For the overall cohort, there was no difference in the rate of CTEPH development based on anticoagulation with a DOAC (5%  versus  8% with warfarin). There were no major bleeding complications with a DOAC.  DOAC therapy appears to be effective and safe in morbid obesity even after intermediate- or high-risk PE. ​

Direct oral anticoagulant therapy in patients with morbid obesity after intermediate- or high-risk pulmonary emboli