Case discussion
The patient caught between evidence and
eminence…
Sylvia Haas, MD, PhD
Emeritus Professor Technical Univ. of Munich,
Germany
Steering Committee Member of GARFIELD
The GARFIELD Registry is funded by an unrestricted research grant
from Bayer Pharma AG
www.tri-london.ac.uk
Disclosures
• Scientific Advisory Board member for Bayer
Healthcare, sanofi-aventis, Bristol-Myers Squibb,
CSL-Behring, Daiichi-Sankyo, ISIS, Sanofi
• Received honoraria from Bayer Healthcare,
Boehringer Ingelheim, Bristol-Myers Squibb,
Daiichi-Sankyo, Pfizer
• GARFIELD inclusion criteria:
– Newly diagnosed non-valvular AF and ≥1 additional
investigator-defined risk factor for stroke
– …
Mr. O.B., 64 y, newly diagnosed AF
CHA2DS2-VASc
Risk Factor
Score
Congestive heart failure/LV
dysfunction
1
Hypertension
1
Age > 75
2
Diabetes
1
Stroke/TIA
2
Vascular disease
1
Age 65-74
1
Sex category (i.e. female)
1
Maximum Score
9
Mr. O.B., 64 y, newly diagnosed AF
CHA2DS2-VASc
Risk Factor
Score
Score Mr. O.B.
Congestive heart failure/LV dysfunction
1
0
Hypertension
1
0
Age > 75
2
0
Diabetes
1
0
Stroke/TIA
2
0
Vascular disease
1
0
Age 65-74
1
0
Sex category (i.e. female)
1
0
Maximum Score
9
0
Newly diagnosed non-valvular AF and ≥1 additional
investigator-defined risk factor for stroke
Clinical pathways and atrial remodeling Bridging obesity and AF
Magnani JW, et al.
Circulation 2013;128:401-405
Mr. O.B., 64 y, newly diagnosed AF
GARFIELD (N=22,261) – Obesity
BMI>30
Mr. O.B.*
189 cm
118 kg
BMI 33 kg/m2
*Cholesterol 290 mg/dl
HDL 40 mg/dl
LDL 167 mg/dl
Mr. O.B., 64 y, BMI 33 kg/m2
The patient has been included in GARFIELD.
 Would you prescribe anticoagulation therapy?
Mr. O.B., 64 y, BMI 33 kg/m2
The investigator prescribed VKA, however it was
difficult to keep the patient in the target range of INR
2.0 – 3.0 (FIR 60%)
FIR=frequency in range (proportion of INR recordings in the therapeutic range)
Poster presentation - Tuesday 2 September
14:00–18:00 poster area of the Central Village
“INR control and 1-year outcomes in patients with newly
diagnosed AF: the GARFIELD Registry”
Sylvia Haas et al., for the GARFIELD-AF Investigators
Unadjusted 1-year outcomes in AF patients according FIR of INR measurements
Effect of BMI on FIR of INR
• The relationship between BMI and FIR is described by a reverse U-shaped curve
with maximum value at about 30 kg/m2.
• FIR increases as the BMI increases up to about 30 kg/m2.
• For patients with BMI higher than 30 kg/m2, FIR decreases as the BMI increases.
Some months later…
Mr. O.B., 65 y, AF, BMI 33 kg/m2
CHA2DS2-VASc
Risk Factor
Score
Score Mr. O.B.
Congestive heart failure/LV dysfunction
1
0
Hypertension
1
1
Age > 75
2
0
Diabetes
1
1
Stroke/TIA
2
0
Vascular disease
1
0
Age 65-74
1
1
Sex category (i.e. female)
1
0
Total Score
9
3
GARFIELD – Obesity
Mr. O.B., CHA2DS2-VASc 3
 Would you convert the patient to a NOAC?
Mr. O.B., CHA2DS2-VASc 3
The patient has been converted to a NOAC
 Would you monitor anticoagulation therapy in this
patient?
Mr. O.B., CHA2DS2-VASc 3
The physician wants to monitor anticoagulation
therapy in this patient
 What guidance can we give?
Mr. O.B.
CHA2DS2-VASc 3 + BMI 33 kg/m2
 The patient suffered ischaemic stroke under NOAC
 Which of the following options would you prefer
for secondary prevention?
From evidence to eminence and back to evidence
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