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.