www.tri-london.ac.uk

The GARFIELD Registry is funded by an unrestricted research grant from Bayer Pharma AG

Lessons Beyond Atrial Fibrillation: Focus on Obesity

Samuel Z. Goldhaber, MDDirector, Thrombosis Research Group

Cardiovascular DivisionBrigham and Women’s Hospital

Professor of MedicineHarvard Medical School

Disclosures

Research Support:

BMS; BTG; Daiichi; NHLBI; Thrombosis Research Institute

Consultant:

Ariad; Bayer; Boehringer-Ingelheim; BMS; Daiichi; Janssen, Merck; Pfizer; Portola

• Stroke Prevention in AF – Obesity, a Risk Factor beyond CHA2DS2-VASc– Obesity’s global burden of disease

• Diet and exercise can reduce AF symptoms and severity (as well as waist circumference and BMI)

• Stroke, venous thromboembolism, and MI share common risk factors, such as obesity

• GARFIELD-AF: will improve our understanding of obesity-AF connection

Learning Objectives

History/Neuro Exam

• 76 y.o. man with hypertension, hyperlipidemia, obesity awakens with garbled speech, nonsense words, confusion. Wife summons Emergency Services.

• BP 185/82 mm Hg; HR 129 irreg irreg; 1.7 meters; 117 kg; BMI=38 kg/m2

• Unable to name months, a pen, a watch, or follow command to show thumb

M2 BRANCH OF MCA: NORMAL

M2 BRANCH OF MCA: CUT OFF

Global Burden of Obesity

• 3.4 million deaths per year • Accounts for 4% of years of life lost• Physical inactivity and carbohydrate-heavy

eating patterns are considered causal• The rise in obesity rates is soaring in

economically developing countries and is slowing down in developed countries

• Prevalence is increasing in children, as well as adults

Ng M, et al. Lancet. 2014; epubl May 29. doi:10.1016/S0140-6736(14)60560-8.

Overweight and Obesity

1980

20001990 2013

38%

Ng M, et al. Lancet. 2014; epubl May 29. doi:10.1016/S0140-6736(14)60560-8.

Obesity Pharmacotherapy

DRUG MECHANISM CV EFFECTS WEIGHTLOSS (%)

Locaserin(Belviq®)

5 HT2C agonist

? Valvulopathy 3.6%

QSymia® GABA modulation

BP, HR elevations

8.6%

Orlistat (Xenical®)

Pancreas, gastric lipase inhibitor

None 2.9% to 3.4%

Apovian CM, et al. Circulation. 2012;125:1178-1182.

Diet/Exercise: Waist Circumference and BMI

• (Abed HS. JAMA 2013; 310: 2050-2060)

Abed HS, et al. JAMA. 2013;310:2050-2060.

Diet/Exercise: AF Symptoms and Severity

Abed HS, et al. JAMA. 2013;310:2050-2060.

Magnani JW, et al. Circulation. 2013;128:401-405.

Magnani JW, et al. Circulation. 2013;128:401-405.

Obesity

Atrial Fibrillation

MI Diabetes

HypertensionOSA

COMMON PATHOPHYSIOLOGY: VTE AND ATHEROSCLEROSIS

(Piazza, Goldhaber. Circulation 2010;121: 2146)

Common Risk Factors and Common Pathophysiology “Lump, Don’t Split”

Stroke

PE + DVTMyocardi

al Infarction

Stroke

Myocardial Infarction

PE + DVT

GARFIELD-AF (N=22,261) - Obesity

BMI>30

Take Home Messages

1. Obesity is a risk factor for developing AF, as well as VTE and MI.

2. Obesity may be a risk factor for stroke in patients with established AF.

3. AF patients should embrace a heart-healthy life style: achieve a BMI < 25 to decrease AF symptom burden and severity.

4. GARFIELD-AF will enlighten obesity-stroke relationship in AF: large sample size, adequate power, pertinent CRF.