Lessons Beyond Atrial Fibrillation: Focus on Obesity
Samuel Z. Goldhaber, MD
Director, Thrombosis Research Group
Cardiovascular Division
Brigham and Women’s Hospital
Professor of Medicine
Harvard Medical School
The GARFIELD Registry is funded by an unrestricted research grant
from Bayer Pharma AG
www.tri-london.ac.uk
Disclosures
Research Support:
BMS; BTG; Daiichi; NHLBI; Thrombosis
Research Institute
Consultant:
Ariad; Bayer; Boehringer-Ingelheim; BMS;
Daiichi; Janssen, Merck; Pfizer; Portola
Learning Objectives
• 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
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
38%
1990
2000
1980
Ng M, et al. Lancet. 2014; epubl May 29. doi:10.1016/S0140-6736(14)60560-8.
2013
Obesity Pharmacotherapy
DRUG
MECHANISM
CV EFFECTS
Locaserin 5 HT2C
(Belviq®) agonist
? Valvulopathy
QSymia®
BP, HR
elevations
None
GABA
modulation
Orlistat
Pancreas,
(Xenical®) gastric lipase
inhibitor
Apovian CM, et al. Circulation. 2012;125:1178-1182.
WEIGHT
LOSS (%)
3.6%
8.6%
2.9% to 3.4%
Diet/Exercise: Waist Circumference and BMI
• (Abed HS. JAMA 2013; 310: 20502060)
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.
Obesity
MI
Diabetes
Hypertension
OSA
Magnani JW, et al. Circulation. 2013;128:401-405.
Atrial
Fibrillation
COMMON PATHOPHYSIOLOGY:
VTE AND ATHEROSCLEROSIS
Common Risk Factors and Common
Pathophysiology “Lump, Don’t Split”
Stroke
Stroke
Myocardial
Infarction
Myocardial
Infarction
PE + DVT
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.