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Case discussion The patient caught between evidence and eminence…

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. Disclosures.

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Case discussion The patient caught between evidence and eminence…

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  1. Case discussionThe patient caught between evidence and eminence… Sylvia Haas, MD, PhD Emeritus Professor Technical Univ. of Munich, Germany Steering Committee Member of GARFIELD

  2. 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

  3. GARFIELD inclusion criteria: • Newly diagnosed non-valvular AF and ≥1 additional investigator-defined risk factor for stroke • …

  4. Mr. O.B., 64 y, newlydiagnosed AF

  5. Mr. O.B., 64 y, newlydiagnosed AF • Newly diagnosed non-valvular AF and ≥1 additional investigator-defined risk factor for stroke

  6. Clinical pathways and atrial remodeling - Bridging obesity and AF Magnani JW, et al. Circulation 2013;128:401-405

  7. GARFIELD (N=22,261) – Obesity Mr. O.B., 64 y, newly diagnosed AF Mr. O.B.* 189 cm 118 kg BMI 33 kg/m2 BMI>30 *Cholesterol 290 mg/dl HDL 40 mg/dl LDL 167 mg/dl

  8. Mr. O.B., 64 y, BMI 33 kg/m2 • The patient has been included in GARFIELD. • Would you prescribe anticoagulation therapy?

  9. 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)

  10. 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

  11. 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.

  12. Some months later…Mr. O.B., 65 y, AF, BMI 33 kg/m2

  13. GARFIELD – Obesity Mr. O.B., CHA2DS2-VASc 3 • Would you convert the patient to a NOAC?

  14. Mr. O.B., CHA2DS2-VASc 3 • The patient has been converted to a NOAC • Would you monitor anticoagulation therapy in this patient?

  15. Mr. O.B., CHA2DS2-VASc 3 • The physician wants to monitor anticoagulation therapy in this patient • What guidance can we give?

  16. Mr. O.B. CHA2DS2-VASc 3 + BMI 33 kg/m2 • The patientsufferedischaemicstrokeunder NOAC • Whichofthefollowingoptionswouldyoupreferforsecondaryprevention?

  17. From evidence to eminence and back to evidence Registries Real world Phase IV studies RCTs controlled double blind RCTs controlled Case controlstudies Case studies Animalresearch In vitro research

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