Rajeev K. Pathak MBBS, PhD. Department of Cardiac Electrophysiology Hospital of University of Pennsylvania
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1 Rajeev K. Pathak MBBS, PhD Department of Cardiac Electrophysiology Hospital of University of Pennsylvania
2 Nil Applicable Disclosure
3 Proportion overweight 70% 60% 50% 40% USA Australia England 30% France 20% Korea Years Sassi et.al, OCED Publishing, 2014
4 Projected number of persons with AF (millions) Year Miyasaka et.al Circulation 2006
5 29% greater AF risk for every 5 BMI units Study Schnabel et al (AGES) Schnabel et al (CHS White) Schnabel et al (CHS African) Smith et al (Men) Smith et al (Women) Tedrow et al Rosengren et al Gami et al Murphy et al Frost et al (Men) Frost et al (Women) Wang et al (Men) Wang et al (Women) Overall (I-squared = 54.7%, p = 0.009) Odds ratio (95% CI) 1.22 (1.05, 1.41) 1.14 (1.05, 1.23) 1.29 (1.10, 1.51) 1.47 (1.34, 1.61) 1.34 (1.22, 1.47) 1.28 (1.16, 1.34) 1.22 (1.10, 1.34) 1.40 (1.28, 1.61) 1.28 (1.05, 1.47) 1.47 (1.28, 1.69) 1.34 (1.16, 1.54) 1.22 (1.05, 1.40) 1.22 (1.05, 1.40) 1.29 (1.23, 1.36) Obesity decreases AF Obesity increases AF Wong CX et al, JACC:EP 2015
6 Tsang et al. EHJ, 2008
7 New Atrial Fibrillation Risk (Frequency) Body Mass Index < >30 < Apnoea-hypopnoea index >40 Gami et al, JACC 2007
8 New Atrial Fibrillation Risk (Hazard Ratio) Stable<30 Stable>30 Increased>30 Reduced<30 Body mass index (Kg/m 2 ) WHS JACC 2010
9 VOL. 65, NO. 20,
10 Assessed for Eligibility N=1415 Patients with BMI 27 N=825 Weight Management Final Cohort N=355 Met Exclusion Criteria (N=293) Terminal Cancer (N=10) Inflammatory Dx (N=20) Permanent AF (N=84) AV Node ablation (N=12) AF ablation (N=90) Severe Medical Illness (N=77) Patients from other States (N=177) <3%WL or WG N= %WL N=103 10%WL N=135
11
12 *Group-Time P<0.001 *Group-Time P<0.001 (ml/m 2 ) (mm)
13 *Group-Time P<0.001 *Group-Time P<0.001
14 P<0.001 Without AAD or ablation 46% 22% 13% Days %WL % WL <3% WL
15 86% 66% With AAD +/- ablation P< % Days %WL % WL <3% WL
16 Yearly Weight Trend (N=344) Effect of Weight Loss Trend Linear Weight Loss N=141 (41%) Weight Fluctuation N=179 (52%) Linear Gain N=24 (7%) Years <2%WF N=54 2-5%WF N=68 >5%WF N=57 Effect of Degree of Weight fluctuation
17 With AAD +/- ablation P< % 59% 38% Days Linear Loss Wt. Fluctuation Linear Gain
18 85% 59% With AAD +/- ablation 44% P<0.001 Days <2% WF % WF >5% WF
19 WL Clinic WL Clinic Total Patients N=135 WL Clinic Total Patients N=103 Total Patients N= WL Clinic 35 (30%) 85% WL Clinic 58 (57%) WL Clinic 113(84 %) 57% 30% 10% WL 3-9 % WL <3% WL 52 patients lost >10% weight in first year 34/52 (66%) maintained WL 30/34 (85%) attended WL clinic 18 regained weight, only 2 (11%) attended clinic
20 Hazard Ratio of CVD Mortality Stable CRF Loss CRF Lee et al. Circulation 2011 Gain CRF Loss BMI Stable BMI Gain BMI
21 VOL. 66, NO. 9,
22 P< % 84% 76% 35% 12% P< % Pathak et al. JACC 2015
23 Exercise stress test Final Cohort N=308 CRF Gain over 10% WL MET Gain <2 N=181 MET Gain 2 N=127 <10% WL + MET Gain <2 N=152 10% WL + MET Gain <2 N=29 <10% WL + MET Gain 2 N=49 10% WL + MET Gain 2 N=78
24 Weight Loss + <2 2 METs Gain Without AAD or ablation 76% 10% WL 10% WL 44% <10% WL 10% WL+MET Gain <2 44% 2MET 32% 37% 31% 2MET 13% <10% 24% WL <10% WL + MET Gain 13% <2
25 Inducible AF Episodes Atrial Fibrosis Baseline Obese AF Inducibility Baseline Over wt Obese Abed H et al, Heart Rhythm 2013 Baseli ne Over wt Obese
26 Control Obese Endo Epi Endo Epi Mahajan R et al, JACC 2015
27 ERP LA pressure LA volume LA strain Munger TM et al, JACC 2012
28 Pathak et al, AHA YIA 2015/CSANZ YIA 2015
29 Hypothesis Aggressive risk factor management, results in reversal of the substrate for AF
30 Patients with BMI risk factors (HTN, DM, OSA, Lipids) N=67 Control Group N=34 Consecutive Patients Symptomatic AF N=112 Randomisation to Aggressive Risk Factor Management ANZCTR : ACTRN RFM Group N=33 Follow Up 3 monthly Exclusion Criteria Previous AF ablation or Permanent AF Amiodarone <6 months H/O Recent MI or cardiac surgery <12M Active malignancy Autoimmune diseases Severe renal or hepatic failure Moved Interstate, N= 7 (4CTL, 3 RFM) Refused further participation, N=10 Baseline Investigations EP study Cardiac MRI + Bloods Mean Follow up : 12.3 ± 1.1 Months 6 months of Standard care N=26 >10% WL + 6 months of RFM N=24 Follow Up Investigations EP study Cardiac MRI + Bloods
31 Weight Management and Exercise Structured Hyperlipidemia Program Dedicated Clinic Lifestyle Glucose Tolerance measures Meal Plan Hypertension Initial Target: >10% WL Final Target: BMI<27kg/m 2 Lifestyle journal 30 minutes 3-4 times weekly to 200 Min At 3 months LDL > 2.6 mmol/l - start statin Add Fibrate if TG > 2.6 mmol/l Start Fibrate if TG > 5.6 mmol/l Glucose tolerance test Lifestyle measures HbA1c> 6.5 at 3 months start Metformin Diabetes clinic Measure BP 2-3 times daily, No added salt diet Aim of : <130/80mmHg at rest < 200/100 at peak exercise Sleep Apnea Formal overnight sleep study AHI 30/hour: CPAP Use Log in diary Tobacco and alcohol use Smoking cessation Alcohol reduction to 30g/week Pathak R et al CJC 2015
32 Mean No. Episodes (n) Total duration of AF (min) Mean Number of AF Episodes Baseline P< % AF free without 1500 AA or Ablation 1000 Follow Up Total Duration of AF Baseline Δ Mean no. AA : Control : 0.4±0.2; RFM Group: - 0.7±0.1 P<0.001 Follow Up
33 Bipolar Voltage (mv) RFM 4 3 P<0.001 Baseline Follow Up Anterior RA HLRA LLRA HSRA LSRA HPRA LPRA
34 Conduction Velocity (mm/ms) RFM 2.1 P<0.02 Baseline Follow Up
35 Obesity is associated with electrical and structural remodeling, increased risk of AF Sustained weight loss is associated with dose dependent reduction in AF burden Cardiorespiratory fitness gain provides incremental gain over weight loss in long-term freedom from AF Weight loss leads to marked improvement in structural and electrical properties of heart A dedicated clinic improves patient engagement, promoting treatment adherence, preventing weight regain and fluctuation
36 Control Group (N=147) RFM Group (N=208) P Value Medication Use Anti-arrhythmic use 0.91 ± ± Anti-Hypertensive medication 0.78± ± Lipid Therapy 81 (64) 73 (40) CPAP Use 62 (43) 70 (34) Interventional Procedure Cardioversion 1.51± ± Single AF Ablation 43 (29) 86 (41) 2nd Procedure 24 (16%) 15 (7) 3rd Procedure 5 (3) 3 (1) In Patient Visits ED presentation 0.76± ±0.5 < Hospitalization for AF 1.15± ± Out Patient Visits Specialist - Planned 14±3 10± Specialist Visit - Unplanned 1.94± ±0.4 <0.001
37
38 Lean Control Obese 15% Wt Loss 30% Wt Loss Mahajan et al, HRS YIA 2013/CSANZ YIA 2013
39 Masson s Trichrome Lean Control Obese 15% Wt Loss 30% Wt Loss p=0.01 p=0.98 p=0.01
40 Lean Control Obese 15% Wt Loss 30% Wt Loss p<0.01 p=0.001 p=0.001
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